Nokea
Which scenarios contribute to effective handoff communicaabitribo.cno ma/tte csth ange of shift? (Select all that apply.)
- A. The nephrology consultant physician is making rounds and asks the nurse to provide an update on the patient’s status and assist in p lacing a central line for hemodialysis.
- B. The noise level is high because twice as many staff me mbers are present and everyone is giving report in the nurse’s station.
- C. The unit has decided to use a standardized checklist/toaobli rbfo.cro mc/hteasnt ge-of-shift reports and patient transfers.
- D. Both the off-going and the oncoming nurses conduct a standardized report at the patient’s bedside and review key assessment findings.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates effective handoff communication by involving key stakeholders (nephrology consultant physician), requesting specific patient updates, and collaborating on patient care tasks (placing a central line). This scenario promotes continuity of care and ensures important information is shared.
Explanation for why other choices are incorrect:
B: High noise level disrupts communication and can lead to errors or omissions in handoff information.
C: While using a standardized checklist can be beneficial, it alone does not guarantee effective communication if not utilized properly or if key information is missed.
D: Conducting reports at the patient's bedside is beneficial for patient involvement but may not address the need for involving relevant healthcare providers like the consultant physician in the handoff process.
You may also like to solve these questions
The nurse notes that a patient’s endotracheal tube (ET), which was at the 22 cm mark, is now at the 25 cm mark and the patient is anxious and restless. Which action should the nurse take next?
- A. Offer reassurance to the patient.
- B. Bag the patient at an FIO2 of 100%.
- C. Listen to the patient’s breath sounds.
- D. Notify the patient’s health care provider.
Correct Answer: C
Rationale: The correct answer is C: Listen to the patient’s breath sounds. Moving from 22 cm to 25 cm may indicate ET tube migration. Checking breath sounds can confirm proper tube placement. A may not address the underlying issue. B could worsen the situation if the tube is misplaced. D is not urgent compared to assessing airway integrity.
The sister of a patient in the ICU has been at the patients bedside non-stop for 48 hours. The nurse suggests to her that she return home to rest. Which of the following is the proper rationale for the nurse making such a suggestion?
- A. The sister is in the way of the health care providers.
- B. The patient may become annoyed by her continual presence.
- C. The patient will recover more easily in peace and quiet.
- D. The sister needs to maintain her own health during this time.
Correct Answer: D
Rationale: The correct answer is D: The sister needs to maintain her own health during this time. It is essential for the sister to take care of her own health and well-being to be able to provide the best support to the patient. Continuous stress and lack of rest can negatively impact her ability to support the patient effectively. Encouraging her to rest will ensure she remains physically and mentally well to continue supporting the patient in the long run.
Incorrect Choices:
A: The sister is in the way of the health care providers - This is incorrect as the primary concern is the well-being of the sister and her ability to provide support.
B: The patient may become annoyed by her continual presence - This is not the main reason for suggesting the sister to rest, as the focus is on her own health.
C: The patient will recover more easily in peace and quiet - While peace and quiet can be beneficial for the patient, the main focus here is on the sister's well-being.
A physician visits a patient in the ICU while the nurse is out. The patient complains that the pain medication is not effective and that he would like to receive an increased dose. The physician has the nurse paged and consults with him in the hallway regarding the patients request for stronger pain medication. The nurse explains that patient was started on a morphine drip only 20 minutes ago and that the drug has not had time to take effectyet. The physician agrees and tells the patient to give it just a bit more time. Which component of a healthy work environment is most evident in this scenario?
- A. Skilled communication
- B. Appropriate staffing
- C. True collaboration
- D. Recognizing signs of imminent stroke and paging the physician
Correct Answer: C
Rationale: The correct answer is C: True collaboration. In this scenario, the physician consults with the nurse to understand the situation and collaborates on the best course of action for the patient's care. This demonstrates effective teamwork, communication, and mutual respect between healthcare professionals, which are key components of a healthy work environment.
Choice A (Skilled communication) is not the best answer because while communication between the physician and nurse is important, the focus in this scenario is more on collaboration and teamwork.
Choice B (Appropriate staffing) is not the best answer as the scenario does not specifically address staffing levels but rather the interaction and collaboration between the physician and nurse.
Choice D (Recognizing signs of imminent stroke and paging the physician) is incorrect as it is unrelated to the scenario described, which is about the physician and nurse collaborating on patient care.
A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action should the nurse include in the plan of care?
- A. Administer prescribed sedatives or opioids at bedtime to promote sleep.
- B. Cluster nursing activities so that the patient has uninterrupted rest periods.
- C. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps.
- D. Eliminate assessments between 0100 and 0600 to allow uninterrupted sleep.
Correct Answer: B
Rationale: The correct answer is B: Cluster nursing activities so that the patient has uninterrupted rest periods.
Rationale:
1. Clustering nursing activities allows for uninterrupted rest periods, essential for improving sleep quality and addressing disturbed sensory perception.
2. Administering sedatives or opioids (Option A) can lead to drug dependence, tolerance, and adverse effects in older adults.
3. Silencing alarms (Option C) compromises patient safety by impeding timely monitoring and response to critical events.
4. Eliminating assessments (Option D) between 0100 and 0600 disregards the necessity of monitoring vital signs and assessing patient condition around the clock.
The nurse is assessing the patient’s pain using the Critical Care Pain Observation Tool (CPOT). Which of the following assessments would indicate the greatest likelihood of pain and need for nursing intervention?
- A. Absence of vocal sounds
- B. Fighting the ventilator
- C. Moving legs in bed
- D. Relaxed muscles in upper extremities
Correct Answer: B
Rationale: The correct answer is B: Fighting the ventilator. This behavior indicates the patient is experiencing discomfort and struggling against the ventilator, suggesting a high likelihood of pain. The CPOT assesses pain through behaviors like grimacing, vocalization, and muscle tension, which are all present when a patient is fighting the ventilator. Absence of vocal sounds (Choice A) does not necessarily indicate pain as some patients may be silent even when in pain. Moving legs in bed (Choice C) could be due to restlessness rather than pain. Relaxed muscles in upper extremities (Choice D) do not reflect pain as the CPOT focuses on behaviors indicating discomfort.