A patient in the ICU is recovering from open-heart surgery. The nurse enters his room and observes that his daughter is performing effleurage on his arms and talking in a low voice about an upcoming family vacation that is planned. The room is dimly lit, and she hears the constant beeping of his heart monitor. From the hall she hears the cries of a patient in pain. Which of the following are likely stressors for the patient? Select all that apply.

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Question 1 of 5

A patient in the ICU is recovering from open-heart surgery. The nurse enters his room and observes that his daughter is performing effleurage on his arms and talking in a low voice about an upcoming family vacation that is planned. The room is dimly lit, and she hears the constant beeping of his heart monitor. From the hall she hears the cries of a patient in pain. Which of the following are likely stressors for the patient? Select all that apply.

Correct Answer: C

Rationale: The correct answer is C: The beeping of the heart monitor is a likely stressor for the patient recovering from open-heart surgery in the ICU. The constant beeping can cause anxiety and uncertainty about their health status. The daughter's conversation and effleurage are likely comforting and supportive for the patient, reducing stress. The dim lighting may create a calming environment, and the distant cries of a patient in pain may evoke empathy but may not directly stress the recovering patient. Therefore, the beeping of the heart monitor stands out as a stressor among the choices provided.

Question 2 of 5

The nurse cares for a terminally ill patient who is experiencing pain that is continuous and severe. How should the nurse schedule the administration of opioid pain medications?

Correct Answer: A

Rationale: The correct answer is A: Give around-the-clock routine administration of analgesics. This is the best approach for managing continuous and severe pain in a terminally ill patient. By providing scheduled doses of opioid pain medications, the nurse ensures a consistent level of pain relief, preventing peaks and troughs in pain control. This approach also helps in preventing the patient from experiencing unnecessary suffering. Choice B (PRN doses) may lead to inadequate pain control as the patient may wait too long before requesting medication. Choice C (keeping the patient sedated) is not appropriate as the goal is pain management, not sedation. Choice D (balancing pain control and respiratory rate) is important, but the priority should be on effectively managing the pain first.

Question 3 of 5

The nurse admits a terminally ill patient to the hospital. What is the first action that the nurse should complete when planning this patient care?

Correct Answer: A

Rationale: The correct answer is A because determining the patient's wishes regarding end-of-life care is crucial in providing patient-centered care and ensuring that the patient's preferences are respected. By understanding the patient's preferences, healthcare providers can tailor the care plan to align with the patient's values and goals. This helps in promoting autonomy, dignity, and quality of life for the patient. Choices B, C, and D are incorrect because although addressing family issues, discussing grief, and encouraging the patient to express fears are important aspects of caring for a terminally ill patient, they are not the first action that should be completed. Prioritizing the patient's wishes ensures that the care plan is centered around the patient's needs and preferences, which is essential in providing holistic and patient-centered care.

Question 4 of 5

A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. Spontaneous re spirations are 12 breaths/min. The patient receives a dose of morphine sulfate, and now respi rations decrease to 4 breaths/min. What adjustments may need to be made to the patient’s ve ntilator settings?

Correct Answer: C

Rationale: The correct answer is C: Change to assist/control ventilation at a rate of 4 breaths/min. When the patient's spontaneous respirations decrease to match the ventilator rate, it indicates that the patient is not actively participating in breathing. Changing to assist/control ventilation allows the patient to trigger breaths when they desire, ensuring a more synchronized and comfortable breathing pattern. A: Adding PEEP may help improve oxygenation but is not directly related to the issue of decreased spontaneous respirations. B: Adding pressure support provides additional support during inspiration but does not address the underlying issue of decreased spontaneous respirations. D: Increasing the SIMV respiratory rate would not address the patient's decreased spontaneous respirations and could potentially lead to overventilation.

Question 5 of 5

The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury. The catheter has been in place for 5 days. The nurse should

Correct Answer: B

Rationale: The correct answer is B because after 5 days, the risk of infection increases. Evaluating the patient for signs and symptoms of infection is crucial for early detection and treatment. Choice A is incorrect because routine dialysis catheter changes are not necessary after only 5 days. Choice C is incorrect as percutaneous catheters are for short-term use. Choice D is incorrect as using the catheter for fluid administration may increase the risk of infection.

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