A nurse walks into a patients room and begins preparing a syringe to perform a blood draw on the patient. The nurse observes that the patient is firmly gripping the side of the bed, averting her eyes, and sweating from her forehead when she sees the needle. What would be the best intervention for the nurse to make?

Correct Answer: D

Rationale: The correct answer is D because it shows empathy and promotes patient education. By describing the procedure and its necessity, the nurse can alleviate the patient's anxiety and build trust. This approach allows the patient to feel informed and in control, reducing fear and increasing cooperation. It also demonstrates respect for the patient's feelings and promotes a therapeutic relationship. Choice A is incorrect as it disregards the patient's fear and can lead to increased distress. Choice B might be an option, but it doesn't address the patient's anxiety in the moment. Choice C, while helpful in some cases, doesn't directly address the patient's specific fear of the blood draw procedure.

Correct Answer: B

Rationale: The correct answer is B: Because the patient is unconscious, complete care as quickly and quietly as possible. This is the most appropriate intervention as it prioritizes the patient's comfort and minimizes unnecessary stimulation. Performing care quickly reduces the time the patient is exposed to potentially uncomfortable procedures. Being quiet also helps create a calming environment for the patient, which is important for someone who is unresponsive. Explanation for other choices: A: Asking a family member to help and discussing family structure is not appropriate as it can be intrusive and may not be relevant or beneficial to the patient's care. C: Informing the patient of the day and time is unnecessary as the patient is unresponsive. Providing care is more crucial than updating the patient. D: Turning on the television is inappropriate as it introduces unnecessary noise and distraction, which can be overwhelming for an unresponsive patient.

Correct Answer: D

Rationale: The correct answer is D: Sensory overload. Constant noise from medical equipment can overwhelm the patient's senses, leading to sensory overload. This can result in increased stress levels, difficulty concentrating, and overall discomfort. Anxiety (A) is related to worry and fear, but in this context, the primary stressor is sensory overload, not anxiety. Pain (B) is a physical sensation, not directly related to the sensory overload caused by noise. Powerlessness (C) refers to a lack of control or influence, which is not the primary form of stress induced by constant noise. Therefore, the correct choice is D as it directly correlates with the impact of the noise on the patient's sensory perception.

Correct Answer: C

Rationale: Rationale: Option C is the correct answer because when caring for a patient with a pulmonary artery catheter receiving continuous enteral feedings, it is crucial to level and zero reference the transducer with the patient's head of bed elevated to 30 degrees. This position helps to ensure accurate hemodynamic measurements, as the head of bed elevation minimizes the impact of intra-abdominal pressure on the catheter readings. By referencing the transducer in this position, the nurse can obtain reliable and precise hemodynamic values. Summary of Incorrect Choices: A: This option is incorrect because delaying documentation until the patient is in the supine position can lead to inaccuracies in the hemodynamic readings due to changes in patient positioning. B: Leveling and zero referencing the transducer with the patient in the supine position is not ideal as it does not account for the impact of intra-abdominal pressure on the catheter readings in patients receiving enteral feedings. D: Leveling and zero referencing

Correct Answer: A

Rationale: The correct answer is A, hypotension. During hemodialysis for acute kidney injury, fluid removal can lead to hypotension due to rapid changes in blood volume. This can cause dizziness, weakness, and even loss of consciousness. Dysrhythmias (choice B) are less common but can occur due to electrolyte imbalances. Muscle cramps (choice C) may occur during or after dialysis due to electrolyte imbalances or fluid shifts, but they are not as common as hypotension. Hemolysis (choice D) is not a common complication of hemodialysis for acute kidney injury, as it is more commonly associated with issues related to the dialysis machine or blood tubing.

Correct Answer: C

Rationale: The correct answer is C: Obtain a portable x-ray to confirm placement. This is the priority intervention because it ensures the arterial line is correctly positioned, reducing the risk of complications such as dislodgement or improper placement. Applying a pressure dressing (choice A) may be necessary but is not the priority. Ensuring tubing connections are tightened (choice B) is important for preventing leaks but does not address placement. Restraining the affected extremity (choice D) is unnecessary and can lead to complications. The x-ray confirms correct placement, ensuring accurate monitoring and treatment.

Correct Answer: B

Rationale: The correct answer is B because a low Mean Arterial Pressure (MAP) indicates inadequate perfusion, which may require adjusting the norepinephrine infusion rate to increase blood pressure. A: A heart rate of 58 beats/minute is within a normal range and may not necessarily indicate a need for adjustment. C: Elevated Systemic Vascular Resistance (SVR) may be an expected response to norepinephrine and does not necessarily indicate a need for adjustment. D: A low Pulmonary Artery Wedge Pressure (PAWP) may indicate fluid volume deficit but does not directly relate to the need for adjusting norepinephrine infusion rate.

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.

Correct Answer: A

Rationale: The correct answer is A: Graduated compression stockings. These stockings help prevent blood from pooling in the legs, reducing the risk of DVT and PE. They improve circulation and reduce venous stasis. Option B, heparin, is used for treatment, not prevention. Option C, sequential compression devices, help prevent DVT but are not as effective as compression stockings. Option D, strict bed rest, can actually increase the risk of DVT by reducing blood flow.