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You are the nurse who is caring for a patient with a newly diagnosed allergy to peanuts. Which of the following is an immediate goal that is most relevant to a nursing diagnosis of deficient knowledge related to appropriate use of an EpiPen?
- A. The patient will demonstrate correct injection technique with todays teaching session.
- B. The patient will closely observe the nurse demonstrating the injection.
- C. The nurse will teach the patients family member to administer the injection.
- D. The patient will return to the clinic within 2 weeks to demonstrate the injection.
Correct Answer: A
Rationale: Immediate goals are those that can be reached in a short period of time. An appropriate immediate goal for this patient is that the patient will demonstrate correct administration of the medication today. The goal should specify that the patient administer the EpiPen. A 2-week time frame is inconsistent with an immediate goal.
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A group of students have been challenged to prioritize ethical practice when working with a marginalized population. How should the students best understand the concept of ethics?
- A. The formal, systematic study of moral beliefs
- B. The informal study of patterns of ideal behavior
- C. The adherence to culturally rooted, behavioral norms
- D. The adherence to informal personal values
Correct Answer: A
Rationale: In essence, ethics is the formal, systematic study of moral beliefs, whereas morality is the adherence to informal personal values.
A care conference has been organized for a patient with complex medical and psychosocial needs. When applying the principles of critical thinking to this patients care planning, the nurse should most exemplify what characteristic?
- A. Willingness to observe behaviors
- B. A desire to utilize the nursing scope of practice fully
- C. An ability to base decisions on what has happened in the past
- D. Openness to various viewpoints
Correct Answer: D
Rationale: Willingness and openness to various viewpoints are inherent in critical thinking; these allow the nurse to reflect on the current situation. An emphasis on the past, willingness to observe behaviors, and a desire to utilize the nursing scope of practice fully are not central characteristics of critical thinkers.
An adult patient has requested a do not resuscitate (DNR) order in light of his recent diagnosis with late stage pancreatic cancer. The patients son and daughter-in-law are strongly opposed to the patients request. What is the primary responsibility of the nurse in this situation?
- A. Perform a slow code until a decision is made.
- B. Honor the request of the patient.
- C. Contact a social worker or mediator to intervene.
- D. Temporarily withhold nursing care until the physician talks to the family.
Correct Answer: B
Rationale: The nurse must honor the patients wishes and continue to provide required nursing care. Discussing the matter with the physician may lead to further communication with the family, during which the family may reconsider their decision. It is not normally appropriate for the nurse to seek the assistance of a social worker or mediator. A slow code is considered unethical.
The nurse is caring for a patient who is withdrawing from heavy alcohol use and who is consequently combative and confused, despite the administration of benzodiazepines. The patient has a fractured hip that he suffered in a traumatic accident and is trying to get out of bed. What is the most appropriate action for the nurse to take?
- A. Leave the patient and get help.
- B. Obtain a physicians order to restrain the patient.
- C. Read the facilitys policy on restraints.
- D. Order soft restraints from the storeroom.
Correct Answer: B
Rationale: It is mandatory in most settings to have a physicians order before restraining a patient. Before restraints are used, other strategies, such as asking family members to sit with the patient, or utilizing a specially trained sitter, should be tried. A patient should never be left alone while the nurse summons assistance.
A terminally ill patient you are caring for is complaining of pain. The physician has ordered a large dose of intravenous opioids by continuous infusion. You know that one of the adverse effects of this medicine is respiratory depression. When you assess your patients respiratory status, you find that the rate has decreased from 16 breaths per minute to 10 breaths per minute. What action should you take?
- A. Decrease the rate of IV infusion.
- B. Stimulate the patient in order to increase respiratory rate.
- C. Report the decreased respiratory rate to the physician.
- D. Allow the patient to rest comfortably.
Correct Answer: C
Rationale: End-of life issues that often involve ethical dilemmas include pain control, do not resuscitate orders, life-support measures, and administration of food and fluids. The risk of respiratory depression is not the intent of the action of pain control. Respiratory depression should not be used as an excuse to withhold pain medication for a terminally ill patient. The patients respiratory status should be carefully monitored and any changes should be reported to the physician.