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Which of the following are components of the Institute for Healthcare Improvement’s (IHI’s) ventilator bundle? (Select all that apply.)
- A. Interrupt sedation each day to assess readiness to extub aa bit re b.. c om/test
- B. Maintain head of bed at least 30 degrees elevation.
- C. Provide deep vein thrombosis prophylaxis.
- D. Provide prophylaxis for peptic ulcer disease.
Correct Answer: A
Rationale: The correct answer is A because interrupting sedation daily to assess readiness to extubate is a key component of IHI's ventilator bundle to prevent ventilator-associated pneumonia. This practice helps prevent over-sedation, reduce the duration of mechanical ventilation, and decrease the risk of complications. The other choices, B, C, and D, are incorrect as they are not specific components of the IHI's ventilator bundle. Maintaining head of bed elevation, providing deep vein thrombosis prophylaxis, and prophylaxis for peptic ulcer disease are important aspects of critical care but are not directly related to the ventilator bundle protocol outlined by IHI.
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Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action?
- A. The right hand is cooler than the left.
- B. The mean arterial pressure (MAP) is 77 mm Hg.
- C. The system is delivering 3 mL of flush solution per hour.
- D. The flush bag and tubing were last changed 3 days previously.
Correct Answer: A
Rationale: The correct answer is A because a cooler right hand may indicate compromised circulation, potentially due to arterial occlusion or clot formation. This could lead to inadequate perfusion and tissue damage. Immediate action is needed to assess and address the cause.
Choice B is incorrect because a MAP of 77 mm Hg is within the normal range for most patients and does not require immediate action.
Choice C is incorrect as delivering 3 mL of flush solution per hour is an appropriate rate and does not indicate a need for immediate action.
Choice D is incorrect as the flush bag and tubing being changed 3 days ago does not necessarily indicate an immediate issue with the arterial line function.
The nurse understands that a patient being cared for in a critical care unit experiences anacute stress response. What nursing action best demonstrates understanding of the physiological parts of the initial stress response?
- A. Adequate pain control
- B. Intravenous sedation
- C. Treatment for elevated blood pressure
- D. Ignoring an elevated glucose level
Correct Answer: C
Rationale: The correct answer is C: Treatment for elevated blood pressure. In the initial stress response, the body releases adrenaline and cortisol, leading to increased heart rate and blood pressure. Treating elevated blood pressure is crucial to prevent complications like heart attack or stroke. Adequate pain control (A) and intravenous sedation (B) may help manage symptoms but do not directly address the physiological response to stress. Ignoring an elevated glucose level (D) is not recommended as stress can impact blood sugar levels. Treatment for elevated blood pressure directly targets the physiological response to stress, making it the best nursing action in this scenario.
Which action is best for the nurse to take to ensure culturally competent care for an alert, terminally ill Filipino patient?
- A. Ask the patient and family about their preferences for care during this time.
- B. Let the family decide whether to tell the patient about the terminal diagnosis.
- C. Obtain information from Filipino staff members about possible cultural needs.
- D. Remind family members that dying patients prefer to have someone at the bedside.
Correct Answer: A
Rationale: The correct answer is A because it promotes patient-centered care by involving the patient and family in decision-making, respecting their autonomy and preferences. This approach acknowledges the importance of cultural beliefs and values in end-of-life care. Choice B undermines patient autonomy by bypassing direct communication with the patient. Choice C assumes all Filipino individuals have the same cultural needs, which is not accurate. Choice D generalizes preferences without considering individual patient needs and wishes. Overall, choice A is the most appropriate as it aligns with the principles of patient-centered care and cultural competence.
The nurse is caring for a critically ill patient with a very concerned family. Given that the family is under high stress, what nursing intervention will best ameliorate their stress while preserving independence?
- A. Encourage the family to participate in patient care tasks.
- B. Teach the family to ask questions of the health care team.
- C. Ask the family to select a family representative for communication.
- D. Limit visits to immediate family members for limited times.
Correct Answer: A
Rationale: The correct answer is A: Encourage the family to participate in patient care tasks. This intervention helps to alleviate stress by involving the family in care, promoting a sense of control and empowerment. It also fosters a collaborative relationship between the family and healthcare team. The other choices are incorrect because B only focuses on asking questions but doesn't actively involve the family in care. C may add pressure on the selected representative and exclude others. D limits family involvement and may increase stress by restricting visitation.
Which patient should the nurse notify the organ procureme nt organization (OPO) to evaluate for possible organ donation?
- A. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram
- B. A 68-year-old male admitted with unstable atrial fibrillation who has suffered a stroke
- C. A 40-year-old brain-injured female with a history of ovabairrbi.acnom c/taenstc er and a Glasgow Coma Scale score of 7
- D. A 53-year-old diabetic male with a history of unstable angina status post resuscitation
Correct Answer: A
Rationale: The correct answer is A because the patient is a 36-year-old with a Glasgow Coma Scale score of 3 and no activity on electroencephalogram, indicating severe brain injury and likely irreversible neurological damage. This patient meets the criteria for potential organ donation as they are neurologically devastated.
Choice B is incorrect because the patient's condition is related to stroke and atrial fibrillation, not severe brain injury that would make them a candidate for organ donation.
Choice C is incorrect because although the patient has a brain injury and a lower Glasgow Coma Scale score, the history of a reversible cause (ovarian cancer metastasis) and a higher GCS score compared to choice A make this patient less suitable for organ donation evaluation.
Choice D is incorrect as the patient's diabetic and cardiovascular history does not suggest severe brain injury that would qualify for organ donation.