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The removal of plasma water and some low–molecular weight particles by using a pressure or osmotic gradient is known as
- A. dialysis.
- B. diffusion.
- C. clearance.
- D. ultrafiltration.
Correct Answer: D
Rationale: Ultrafiltration is the correct answer because it involves the removal of plasma water and low-molecular weight particles by using a pressure or osmotic gradient. During ultrafiltration, the pressure gradient pushes the fluid through a semipermeable membrane, separating the substances based on their molecular size. This process allows for the selective removal of unwanted substances while retaining essential components. Dialysis (choice A) involves the removal of waste products from the blood, but it does not specifically target plasma water and low-molecular weight particles. Diffusion (choice B) is the passive movement of particles from an area of higher concentration to an area of lower concentration and is not specific to the removal of plasma water. Clearance (choice C) refers to the rate at which a substance is removed from the blood and does not involve the mechanism of pressure or osmotic gradient utilized in ultrafiltration.
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Family assessment is essential in order to meet family nee ds. Which of the following must be assessed first to assist the nurse in providing family-centered care?
- A. Assessment of patient and family’s developmental stag es and needs
- B. Description of the patient’s home environment
- C. Identification of immediate family, extended family, a nd decision makers
- D. Observation and assessment of how family members fu nction with each other
Correct Answer: A
Rationale: The correct answer is A because assessing the patient and family's developmental stages and needs is crucial in understanding their current situation and determining the appropriate care plan. By assessing developmental stages, the nurse can tailor interventions to meet the family's specific needs. This assessment also helps in identifying potential challenges or areas requiring support.
Choice B is incorrect as it focuses solely on the physical environment and does not address the family's developmental stages and needs.
Choice C is incorrect as it emphasizes identifying family members without considering the importance of understanding their developmental stages and needs in providing family-centered care.
Choice D is incorrect as it concentrates on family dynamics without directly addressing the crucial aspect of assessing developmental stages and needs for effective family-centered care.
The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows ventricular tachycardia. The patient does not have a “do not resuscitate” order written on the chart. What is the appropriate nursing action?
- A. Contact the attending physician immediately to determ ine if CPR should be initiated.
- B. Contact the family immediately to determine if they waabnirtb .CcoPmR/te stot be started.
- C. Give emergency medications but withhold intubation.
- D. Initiate CPR and call a code.
Correct Answer: D
Rationale: The correct answer is D: Initiate CPR and call a code. In this scenario, the patient is critically ill with ventricular tachycardia, a life-threatening arrhythmia. Since there is no "do not resuscitate" order, the appropriate nursing action is to initiate CPR immediately to attempt to restore the patient's cardiac function and circulation. Calling a code will ensure that a team of healthcare providers can respond promptly with necessary interventions. Options A and B involve unnecessary delays in potentially life-saving interventions. Option C is incorrect as withholding intubation can compromise the patient's airway and oxygenation. Thus, option D is the most appropriate action to prioritize the patient's safety and well-being in this critical situation.
The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document that indicates a successful outcome?
- A. Demonstrates adequate fluid intake and output.
- B. Verbalizes abdominal comfort without pressure.
- C. Drinks 240 mL of fluid five times during the shift.
- D. Voids at least 1000 mL between 7 am and 3 pm.
Correct Answer: C
Rationale: Step 1: The objective is for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm.
Step 2: Choice C states that the client drinks 240 mL of fluid five times during the shift, totaling 1200 mL (240 mL x 5) which exceeds the required amount.
Step 3: Therefore, choice C is the correct answer as it demonstrates successful achievement of the objective by ensuring the client has ingested enough fluid within the specified time frame.
Step 4: Choices A, B, and D are incorrect as they do not directly address the specific objective of fluid intake set for the client. Option A focuses on intake and output, option B relates to abdominal comfort, and option D is about voiding, none of which directly address the specified objective of fluid ingestion.
The son of a dying patient tells the nurse, 'Mother doesn’t respond anymore when I visit. I don’t think she knows that I am here.' Which response by the nurse is appropriate?
- A. You may need to cut back your visits, for now, to avoid overtiring your mother.
- B. Withdrawal may sometimes be a normal response when preparing to leave life.
- C. It will be important for you to stimulate your mother as she gets closer to dying.
- D. Many patients don’t know what is going on around them at the end of life.
Correct Answer: B
Rationale: The correct answer is B because withdrawal is a common psychological response in the dying process. The nurse should explain to the son that his mother's lack of response may be her way of preparing to leave life. This response validates the son's concerns while providing reassurance.
Choice A is incorrect because cutting back visits may not address the underlying issue of the mother's withdrawal. Choice C is incorrect because stimulating the mother may not be beneficial or appropriate in this situation. Choice D is incorrect because not all patients experience a lack of awareness at the end of life, and assuming so may not be helpful in this context.
What nonpharmacological approaches to pain and/or anxie ty may best meet the needs of critically ill patients? (Select all that apply.)
- A. Anaerobic exercise
- B. Art therapy
- C. Guided imagery
- D. Music therapy
Correct Answer: B
Rationale: The correct answer is B: Art therapy. Art therapy can help critically ill patients express emotions, reduce anxiety, and cope with pain in a nonverbal way. It provides a creative outlet for self-expression and can improve overall well-being. Anaerobic exercise (A) may not be suitable for critically ill patients due to physical limitations. Guided imagery (C) may not be effective for all patients and requires a certain level of cognitive ability. Music therapy (D) can be beneficial, but art therapy is specifically known for its effectiveness in addressing emotional and psychological needs in critically ill patients.