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While caring for a critically ill patient, the nurse knows that fostering patient control over the environment is a method for stress reduction. What nursing intervention gives the patient the most environmental control while still adhering to best practice principles?
- A. Ask the patient whether he or she wants to get out of bed.
- B. Give the patients bath at the same time every day.
- C. Explain painful procedures only after giving pain medication.
- D. Choose menu items for the patient to ensure a balanced diet.
Correct Answer: A
Rationale: Step 1: Asking the patient whether he or she wants to get out of bed allows the patient to make a decision regarding their immediate environment, promoting autonomy and control.
Step 2: This intervention respects the patient's preferences and fosters a sense of dignity and empowerment, reducing stress.
Step 3: Best practice principles in nursing emphasize patient-centered care and promoting patient autonomy.
Summary:
Choice A is correct as it directly involves the patient in decision-making, enhancing their sense of control. Choices B, C, and D do not provide the same level of autonomy and control to the patient, making them less effective in reducing stress and promoting patient well-being.
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When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)?
- A. Assist with endotracheal intubation.
- B. Insert an indwelling urinary catheter.
- C. Begin continuous cardiac monitoring.
- D. Obtain an order to restrain the patient.
Correct Answer: C
Rationale: Rationale:
Continuous cardiac monitoring is crucial during therapeutic hypothermia to monitor the patient's cardiac rhythm and detect any arrhythmias promptly. This intervention allows for immediate intervention if any cardiac issues arise.
Explanation of other choices:
A: Assisting with endotracheal intubation may be necessary for airway management but is not directly related to cooling the patient for therapeutic hypothermia.
B: Inserting an indwelling urinary catheter may be needed for urine output monitoring but is not a priority intervention for cooling the patient.
D: Restraining the patient is unnecessary and not indicated for therapeutic hypothermia; it may cause unnecessary distress and should be avoided unless absolutely necessary for patient safety.
The charge nurse is supervising the care of four critical ca re patients being monitored using invasive hemodynamic modalities. Which patient should t he charge nurse evaluate first?
- A. A patient in cardiogenic shock with a cardiac output (CabOirb). coofm 2/te.0st L/min
- B. A patient with a pulmonary artery systolic pressure (PA P) of 20 mm Hg
- C. A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg
- D. A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg
Correct Answer: A
Rationale: The correct answer is A because the patient in cardiogenic shock with a cardiac output of 2.0 L/min is experiencing a life-threatening condition that requires immediate evaluation. Cardiogenic shock indicates poor cardiac function, which can lead to multi-organ failure. Monitoring cardiac output is crucial in managing these patients.
Choice B is incorrect because a pulmonary artery systolic pressure of 20 mm Hg is within normal range and does not indicate an immediate life-threatening condition.
Choice C is incorrect because a CVP of 6 mm Hg in a hypovolemic patient may indicate volume depletion, but it is not as urgent as the patient in cardiogenic shock.
Choice D is incorrect because a PAOP of 10 mm Hg is within normal range and does not suggest an immediate critical condition.
A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT?
- A. New ST segment elevation is noted on the cardiac monitor.
- B. Enteral feedings are being given through an orogastric tube.
- C. Scattered rhonchi are heard when auscultating breath sounds.
- D. HYDROmorphone (Dilaudid) is being used to treat postoperative pain.
Correct Answer: A
Rationale: The correct answer is A: New ST segment elevation is noted on the cardiac monitor. This finding is concerning because it may indicate myocardial ischemia or infarction, which can be exacerbated by the physiological stress of weaning from mechanical ventilation. It is crucial to address any cardiac issues before initiating a spontaneous breathing trial to prevent potential cardiac complications during the weaning process.
Explanation for why the other choices are incorrect:
B: Enteral feedings being given through an orogastric tube are not contraindicated for starting a spontaneous breathing trial.
C: Scattered rhonchi heard when auscultating breath sounds may indicate retained secretions but are not a contraindication for a spontaneous breathing trial.
D: The use of HYDROmorphone to treat postoperative pain is not a contraindication for a spontaneous breathing trial unless it is causing respiratory depression, which would need to be addressed separately.
After attending an educational program, the nurse understaanbidrbs.c othma/tte swt hich the following situations would require an ethics consultation?
- A. Conflict has occurred between the primary care provid er and family regarding treatment decisions. A family conference is held, and the family and primary care provider agree to a treatment plan that includes aggres sive treatment for 24 hours followed by re-evaluation.
- B. Family members disagree as to a patient’s course of tre atment. The patient has designated a healthcare proxy and has a written advancaebi rdb.icroemc/tteivste .
- C. A postoperative coronary artery bypass surgery patient was successfully resuscitated after sustaining a cardiopulmonary arrest i n the operating room The patient who is now not responding to treatment has a written advance directive and has a life partner at the bedside.
- D. Patient with multiple trauma and is not responding to treatment. No family members are known, and care is considered futile.
Correct Answer: D
Rationale: Step 1: The correct answer is D because the situation involves a patient with multiple trauma who is not responding to treatment and has no known family members. This indicates a complex ethical dilemma where the medical team may be unsure about the appropriate course of action.
Step 2: In this scenario, an ethics consultation is necessary to help guide decision-making regarding the care of the patient. The lack of available family members complicates decision-making, and the consideration of care as futile adds another layer of complexity.
Step 3: An ethics consultation can provide a structured framework for evaluating the situation, considering ethical principles such as beneficence, non-maleficence, autonomy, and justice. It can help the healthcare team navigate the ethical considerations and make a well-informed decision in the best interest of the patient.
Summary:
Choice A: While conflicts between the primary care provider and family may warrant discussions, the agreement on a treatment plan does not necessarily require an ethics consultation.
Choice B: Disagreement
The nurse notes premature ventricular contractions (PVCs) while suctioning a patient’s endotracheal tube. Which action by the nurse is a priority?
- A. Decrease the suction pressure to 80 mm Hg.
- B. Document the dysrhythmia in the patient’s chart.
- C. Stop and ventilate the patient with 100% oxygen.
- D. Give antidysrhythmic medications per protocol.
Correct Answer: C
Rationale: The correct answer is C: Stop and ventilate the patient with 100% oxygen. This is the priority action because PVCs can lead to life-threatening arrhythmias and inadequate oxygenation. By stopping suctioning and providing 100% oxygen, the nurse ensures proper oxygenation and ventilation, which takes precedence over addressing the dysrhythmia itself. Decreasing suction pressure (choice A) may not address the underlying issue and could potentially harm the patient. Documenting the dysrhythmia (choice B) is important but not as urgent as ensuring adequate oxygenation. Giving antidysrhythmic medications (choice D) should be done under the direction of a healthcare provider and is not the first-line intervention in this situation.