A critically ill patient experiences stress and anxiety from many factors. Treatment of the patient focuses on reducing stressors and providing supportive care such as nutrition, oxygenation, pain management, control of anxiety, and specific care of the illness or injury. What is the best rationale for these interventions?

Correct Answer: A

Rationale: The correct answer is A: Helps to support the patient's immune system. Providing supportive care such as nutrition, oxygenation, pain management, and anxiety control can help reduce stress, which in turn supports the immune system. Stress weakens the immune system, making the patient more vulnerable to infections and complications. By addressing stress and anxiety through supportive care, the patient's immune system is better able to function optimally, aiding in the recovery process. Choices B, C, and D are incorrect because: B: Part of good nursing care - While supportive care is indeed part of good nursing care, the key rationale for these interventions in a critically ill patient is to support the immune system, not just to provide good nursing care. C: Mandated by hospital policy - Hospital policies may dictate certain aspects of care, but the primary goal of these interventions is to support the patient's immune system, not just to comply with hospital policies. D: Reassures the patient and family - While providing reass

Correct Answer: E

Rationale: The correct answer is not provided, but based on the events described, the official time of death recorded in the medical record should be 1810 (Choice D). At this time, the cardiac monitor shows flatline, indicating the cessation of cardiac activity, which is the universally accepted point of declaring death. Choice A (1300) is incorrect because that is when diagnostic tests for brain death were completed, but the patient was not officially declared dead at that time. Choice B (1330) is incorrect as this is when the primary care provider reviewed the test results and documented brain death in the progress note, but the patient was not officially declared dead at this time either. Choice C (1400) is incorrect as there is no significant event occurring at this time that signifies the patient's death. Therefore, the most appropriate and official time of death recorded in the medical record would be 1810 when the cardiac monitor shows flatline.

Correct Answer: A

Rationale: The correct answer is A because continuous venovenous hemofiltration (CVVH) primarily removes fluids and solutes through the process of convection. In CVVH, blood flows through a filter where hydrostatic pressure drives plasma water and solutes across a semipermeable membrane. This process mimics the natural filtration that occurs in the kidneys. Choice B is incorrect because CVVH does not specifically target plasma water only but also removes solutes. Choice C is incorrect because CVVH does not involve adding dialysate to remove plasma water and solutes. Choice D is incorrect because while CVVH may involve ultrafiltration and convection, it does not typically include dialysis as a primary mechanism for solute removal.

Correct Answer: D

Rationale: The correct answer is D because after arteriovenous fistula implantation, it is essential to assess for the presence of a bruit (audible sound caused by turbulent blood flow) and thrill (vibratory sensation) in the access site, which indicates proper functioning of the fistula. This assessment ensures that blood is flowing adequately through the newly created access for dialysis or other procedures. Drawing blood or taking blood pressures from the fistula arm can lead to complications such as clot formation or damage to the fistula. Starting a new IV line in the same arm is contraindicated to avoid compromising the newly created fistula. Thus, auscultating for a bruit and palpating for a thrill are the appropriate nursing actions in this scenario.

Correct Answer: D

Rationale: The correct answer is D: A patient with paradoxical chest movements. This indicates flail chest, a life-threatening condition where a segment of the chest wall moves independently from the rest. 1. Flail chest can lead to respiratory compromise and potential respiratory failure. 2. Immediate intervention is needed to stabilize the chest wall and support breathing. 3. Without prompt treatment, the patient can develop hypoxia and potentially progress to cardiac arrest. Summary: - Choice A: No pedal pulses may indicate vascular compromise but does not pose an immediate threat to life. - Choice B: Open femur fracture requires urgent treatment but does not have the same immediate life-threatening implications as flail chest. - Choice C: Bleeding facial lacerations can be managed after addressing more critical injuries like flail chest.

Correct Answer: D

Rationale: The correct answer is D: “Recovery is possible, but it may take several months.” This response is the best choice as it provides a balanced and accurate explanation to the patient. Here's the rationale: 1. Hemodialysis is often used as a temporary measure to support kidney function while allowing time for the kidneys to recover. 2. Acute kidney injury can be reversible in some cases, especially if the underlying cause is identified and treated promptly. 3. Recovery time varies for each individual, and it can indeed take several months for kidney function to improve. 4. Choices A, B, and C are incorrect: - A is overly pessimistic and does not consider the potential for recovery. - B provides a specific timeframe that may not be accurate for all patients. - C is not a reliable indicator of kidney function recovery and may lead to confusion.

Correct Answer: C

Rationale: Correct Answer: C - Regular insulin Rationale: 1. Insulin promotes cellular uptake of potassium. 2. When insulin is administered, it moves potassium from extracellular to intracellular space. 3. This decreases plasma potassium levels safely. 4. Other options do not directly lower potassium levels in the same manner. Summary of Other Choices: A: Sodium polystyrene sulfonate - exchanges sodium for potassium in the intestines, not reducing total body potassium. B: Sodium polystyrene sulfonate with sorbitol - similar to A, does not reduce total body potassium. D: Calcium gluconate - does not directly lower potassium levels, used for treating hyperkalemia-induced cardiac toxicity.

Correct Answer: D

Rationale: The correct action is D: Manually ventilate the patient with 100% oxygen. This is crucial to ensure adequate oxygenation and prevent hypoxia. Holding the ET tube can lead to extubation and airway compromise. Activating the rapid response team (A) may delay immediate intervention. Providing reassurance (B) is important but not the priority in this situation. Calling the health care provider (C) to reinsert the tube would also lead to a delay in providing essential respiratory support.

Correct Answer: C

Rationale: First, the nurse should assess the patient's lungs to rule out any potential respiratory issues causing fluid retention. This is crucial as the patient has signs of fluid imbalance with decreased output and increased weight. Assessing the lungs can help identify conditions like heart failure or pneumonia that may contribute to these changes. Drawing a trough level (choice A) is not a priority as it doesn't address the immediate concern of fluid imbalance. Placing the patient on fluid restriction (choice B) should only be done after identifying the cause of the imbalance. Inserting an indwelling catheter (choice D) is not necessary at this point as the issue is related to fluid balance, not urinary elimination.