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The nurse is preparing to provide postmortem care for a patient who has just died. Which action should the nurse take first?
- A. Close the patient’s eyes and place a pillow under the head.
- B. Wash the patient’s body and apply a clean gown.
- C. Remove all medical equipment and tubes.
- D. Confirm that a death certificate has been signed.
Correct Answer: A
Rationale: Rationale:
A: Closing the patient's eyes and placing a pillow under the head is the first step in postmortem care to maintain dignity and prevent airway occlusion.
B: Washing the body and changing clothes can be done later and is not the priority.
C: Removing medical equipment can wait until after ensuring the patient's comfort.
D: Confirming the death certificate is important but not the immediate first step in postmortem care.
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The nurse is caring for a patient with severe neurological impairment following a massive stroke. The primary care provider has ordered tests to detearbmirbi.ncoem b/treasit n death. The nurse understands that criteria for brain death includes what crite ria? (Select all that apply.)
- A. Absence of cerebral blood flow.
- B. Absence of brainstem reflexes on neurological examin ation.
- C. Presents of Cheyne-Stokes respirations.
- D. Confirmation of a flat electroencephalogram.
Correct Answer: A
Rationale: The correct answer is A: Absence of cerebral blood flow. Brain death is determined by the irreversible cessation of all brain functions, including blood flow to the brain. When there is no cerebral blood flow, the brain is unable to function, leading to brain death. This criterion is essential in diagnosing brain death as it indicates a complete loss of brain function.
Explanation for why the other choices are incorrect:
- B: Absence of brainstem reflexes on neurological examination is a common sign of brain death, but it is not the primary criterion.
- C: Presence of Cheyne-Stokes respirations is not indicative of brain death. It is a pattern of breathing that can be seen in various conditions, not specifically brain death.
- D: Confirmation of a flat electroencephalogram is a supportive test for brain death but not the primary criterion. The absence of brain activity on an EEG can help confirm brain death but is not as definitive as the absence of cerebral blood flow.
The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?
- A. Tracheostomy tube suctioning.
- B. Medication administration.
- C. Colostomy care instruction.
- D. Client personal hygiene.
Correct Answer: B
Rationale: The correct answer is B: Medication administration. This is the priority because medication administration is time-sensitive and crucial for patient safety. It requires precise timing and cannot be delayed. Tracheostomy tube suctioning (A), colostomy care instruction (C), and client personal hygiene (D) are important nursing activities but can be adjusted within the schedule based on patient needs and acuity levels. Prioritizing medication administration ensures that patients receive their medications on time, preventing adverse events and promoting optimal health outcomes.
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.
A client has been admitted after experiencing multiple trauma and is intubated and sedated. When the five members of the immediate family arrive, they are anxious, angry, and very demanding. They all speak loudly at once and ask for many services and answers. What is the best nursing response?
- A. Ask the family to leave until visiting hours begin.
- B. Take them to a private area for initial explanations.
- C. Page security to have them removed from unit.
- D. Show them to the clients bedside and leave them alone.
Correct Answer: B
Rationale: The correct answer is B: Take them to a private area for initial explanations. This response is the best because it allows the nurse to address the family's concerns in a private and controlled environment. It promotes effective communication and enables the family to express their emotions and receive information without distractions.
Choice A is incorrect because asking the family to leave may escalate the situation and not address their needs. Choice C is inappropriate as paging security to remove the family can worsen the family's distress and hinder communication. Choice D is not ideal as leaving the family alone may lead to misunderstandings and increased anxiety. Overall, choice B is the most therapeutic and effective approach in this situation.
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.