The nurse is caring for a terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be most appropriate?

Correct Answer: D

Rationale: The correct answer is D because the patient is exhibiting Cheyne-Stokes breathing pattern characterized by periods of apnea followed by deep and rapid breathing. The nurse should document this pattern accurately. Option A is incorrect as suctioning is not indicated. Option B may worsen the respiratory pattern. Option C is not specifically related to addressing the breathing pattern.

Correct Answer: B

Rationale: The correct answer is B: Provide emotional support and comfort measures. In the final stages of dying, the focus shifts from curative treatment to providing comfort and dignity. Emotional support helps alleviate anxiety and fear, promoting a peaceful transition. Comfort measures like pain management improve quality of life. Encouraging the patient to eat may be futile as the body shuts down. Performing frequent assessments for recovery signs is not appropriate in this situation. Implementing aggressive interventions could go against the patient's wishes for a natural death.

Correct Answer: A

Rationale: The correct answer is A: Evidence-based practice. The AACN Standards for Acute and Critical Care Nursing Practice emphasize the use of evidence-based practice to guide critical care nursing. This framework ensures that nursing interventions are based on the best available evidence, leading to improved patient outcomes. Healthy work environment (B) and National Patient Safety Goals (C) are important but not specific frameworks for critical care nursing. The nursing process (D) is a systematic approach to delivering patient care but is not the primary guiding framework in critical care nursing practice.

Correct Answer: A

Rationale: The correct answer is A: Clinical practice guidelines. Clinical practice guidelines are evidence-based recommendations that assist nurses in providing appropriate care based on research. They outline best practices for specific patient populations or conditions, helping nurses make informed decisions. Summary: - B: Computerized physician order entry: While it may improve accuracy and efficiency, it does not specifically ensure care based on research. - C: Consulting with advanced practice nurses: While collaboration is valuable, it does not guarantee care based on research. - D: Implementing Joint Commission National Patient Safety Goals: Important for patient safety, but not directly related to ensuring care based on research.

Correct Answer: A

Rationale: Rationale: Accurately identifying patients is a National Patient Safety Goal to prevent errors in patient care. Proper patient identification ensures correct treatments and medications are given, reducing harm. Restraint elimination, medication reconciliation, and infection reduction are important goals but not specific National Patient Safety Goals. Accurate patient identification directly addresses patient safety concerns.