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?

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Question 1 of 9

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.

Question 2 of 9

The patient’s potassium level is 7.0 mEq/L. Besides dialysis, which of the following actually reduces plasma potassium levels and total body potassium content safely in a patient with renal dysfunction?

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.

Question 3 of 9

After attending an educational program, the nurse understaanbidrbs.c othma/tte swt hich the following situations would require an ethics consultation?

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

Question 4 of 9

The nurse is concerned that the patient will pull out the en dotracheal tube. As part of the nursing management, the nurse should obtain an order for what intervention?

Correct Answer: A

Rationale: The correct answer is A. A Posey-type vest is a restraint designed to prevent patients from pulling out medical devices like endotracheal tubes, ensuring their safety. It is a less restrictive option compared to wrist restraints and sedatives (B and C), which can have adverse effects and may not directly address the concern of tube removal. Using a Posey-type vest promotes patient autonomy by allowing some movement while still providing the necessary protection.

Question 5 of 9

When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)?

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.

Question 6 of 9

The nurse is caring for 80-year-old patient who has been tr eated for gastrointestinal bleeding. The family has agreed to withhold or withdraw additional treatment. The patient has a written advance directive specifying requests. The directive notes that the patient wants food and fluid to be continued and to be made physically comfortable. Th e nurse anticipates that several orders may be written to comply with this request, including which of the following? (Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A: "Do not resuscitate." In this scenario, the patient's advance directive specifies a desire for comfort measures and continuation of food and fluids. A DNR order aligns with this directive by respecting the patient's wish to avoid aggressive life-saving measures. This choice prioritizes the patient's autonomy and quality of life. Other options (B, C, D) are not aligned with the patient's wishes. Changing antibiotics or stopping blood transfusions may be unrelated to the patient's comfort or food/fluid preferences. Discontinuing tube feeding goes against the directive's request for food and fluid continuation.

Question 7 of 9

Anxiety differs from pain in that way? (Select all that app ly.)

Correct Answer: B

Rationale: The correct answer is B because anxiety is indeed linked to reward and punishment centers in the limbic system, specifically involving the amygdala and prefrontal cortex. This connection influences emotional responses and behaviors related to anxiety. Choices A, C, and D are incorrect because anxiety involves both neurological and psychological processes beyond the brain, is highly subjective like pain, and can lead to physical symptoms without actual tissue injury.

Question 8 of 9

The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include whic h intervention?

Correct Answer: D

Rationale: The correct answer is D: Mobility. Maintaining mobility helps prevent blood stasis, a leading factor in the development of pulmonary embolism. Movement promotes circulation, reducing the risk of blood clots. A: Antiseptic oral care is important for oral hygiene but not directly related to preventing pulmonary embolism. B: Bed rest with head of bed elevated can actually increase the risk of clots due to immobility. C: Coughing and deep breathing are beneficial for preventing respiratory complications but do not address the underlying cause of pulmonary embolism.

Question 9 of 9

What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period?

Correct Answer: C

Rationale: The correct answer is C: Primary nursing. Primary nursing is a care delivery model where one nurse is responsible for the total care of a group of clients over a 24-hour period. This promotes continuity of care, individualized attention, and better nurse-client relationships. In primary nursing, the nurse plans and directs care, coordinates with other healthcare team members, and serves as the main point of contact for the clients. A: Case management involves coordinating care across different healthcare providers and services, not necessarily focusing on a specific group of clients over a 24-hour period. B: Team nursing involves a team of healthcare providers working together to deliver care, rather than one nurse being responsible for a specific group of clients over a 24-hour period. D: Functional nursing divides tasks among different healthcare team members based on their specific skills, which may not provide the same level of continuity and individualized care as primary nursing.

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