The sister of a patient in the ICU has been at the patients bedside non-stop for 48 hours. The nurse suggests to her that she return home to rest. Which of the following is the proper rationale for the nurse making such a suggestion?

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Question 1 of 9

The sister of a patient in the ICU has been at the patients bedside non-stop for 48 hours. The nurse suggests to her that she return home to rest. Which of the following is the proper rationale for the nurse making such a suggestion?

Correct Answer: D

Rationale: The correct answer is D: The sister needs to maintain her own health during this time. It is essential for the sister to take care of her own health and well-being to be able to provide the best support to the patient. Continuous stress and lack of rest can negatively impact her ability to support the patient effectively. Encouraging her to rest will ensure she remains physically and mentally well to continue supporting the patient in the long run. Incorrect Choices: A: The sister is in the way of the health care providers - This is incorrect as the primary concern is the well-being of the sister and her ability to provide support. B: The patient may become annoyed by her continual presence - This is not the main reason for suggesting the sister to rest, as the focus is on her own health. C: The patient will recover more easily in peace and quiet - While peace and quiet can be beneficial for the patient, the main focus here is on the sister's well-being.

Question 2 of 9

In which situation would a healthcare surrogate or proxy a ssume the end-of-life decision-making role for a patient?

Correct Answer: A

Rationale: The correct answer is A because in this situation, the patient is no longer able to make decisions for themselves due to being heavily sedated. The healthcare surrogate or proxy steps in to make decisions on behalf of the patient to ensure their comfort and well-being. Choice B is incorrect because the patient is competent and able to make their own decisions, so there is no need for a surrogate to take over decision-making. Choice C is incorrect because the patient is competent and has the right to make decisions about their own treatment, even if they go against medical recommendations. Choice D is incorrect because the patient is competent and receiving appropriate treatment for their pain and anxiety, so there is no need for a surrogate to intervene in this scenario.

Question 3 of 9

A 65-year-old patient admitted to the progressive care unit with a diagnosis of community-acquired pneumonia, has a history of chronic obstructive pulmonary disease and diabetes. A set of arterial blood gases obtained on admissiaobnir bw.coitmh/oteustt supplemental oxygen shows pH 7.35; PaCO 55 mm Hg; bicarbonate 30 mEq/L ; PaO 65 mm Hg. These blood 2 2 gases reflect what condition?

Correct Answer: B

Rationale: The correct answer is B: Hypoxemia and compensated respiratory acidosis. The patient's pH is within normal range (7.35), indicating compensation. The elevated PaCO2 (55 mm Hg) indicates respiratory acidosis due to inadequate ventilation, likely from COPD. The low PaO2 (65 mm Hg) indicates hypoxemia, common in pneumonia. The normal bicarbonate level (30 mEq/L) suggests metabolic compensation for respiratory acidosis. Choice A is incorrect as there is no metabolic alkalosis present. Choice C is incorrect as the patient has hypoxemia. Choice D is incorrect as the patient is showing compensated respiratory acidosis, not uncompensated.

Question 4 of 9

The nurse is using presence to reduce the anxiety of a critically ill patient. What nursing behavior demonstrates an effective use of presence?

Correct Answer: C

Rationale: The correct answer is C because maintaining eye contact with the patient during explanations is a non-verbal way to show attentiveness and empathy, which can help reduce the patient's anxiety. This behavior demonstrates active listening and engagement, making the patient feel heard and understood. A: Staying in the patient's room to complete documentation is not an effective use of presence as it does not involve direct interaction with the patient. B: Having a conversation in the patient's room that excludes the patient is also not an effective use of presence as it does not involve engaging with the patient. D: Focusing on specific nursing care tasks while in the patient's room, although important, may not necessarily demonstrate presence in reducing the patient's anxiety.

Question 5 of 9

The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 12 5 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO ) of 90% on a 50% venturi mask. 2 Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pres sure (PAOP) of 3 mm Hg. The nurse questions which of the following primary health care provider’s order?

Correct Answer: D

Rationale: The correct answer is D: Administer furosemide 20 mg intravenously. In this scenario, the patient is hypotensive with a low cardiac output, low CVP, and low PAOP, indicating cardiogenic shock. Administering furosemide, a diuretic, can worsen the patient's condition by further decreasing preload. This can lead to a decrease in cardiac output and exacerbate the shock state. The other options are more appropriate: A: Titrate supplemental oxygen to achieve a SpO > 94% - Correct, as improving oxygenation is essential in cardiogenic shock. B: Infuse 500 mL 0.9% normal saline over 1 hour - Correct, as fluid resuscitation may be necessary to improve perfusion. C: Obtain arterial blood gas and serum electrolytes - Correct, as these tests provide valuable information about the patient's oxygenation and electrolyte balance.

Question 6 of 9

A middle-aged patient tells the nurse, 'My mother died 4 months ago, and I just can’t seem to get over it. I’m not sure it is normal to still think about her every day.' Which nursing diagnosis is most appropriate?

Correct Answer: C

Rationale: The correct answer is C: Anxiety related to lack of knowledge about normal grieving. This is because the patient is expressing uncertainty and seeking validation for their feelings, indicating a lack of understanding about the grieving process. Choice A is incorrect as hopelessness typically involves feelings of despair and loss of motivation, which are not explicitly stated by the patient. Choice B is incorrect as complicated grieving involves specific unresolved issues related to the loss, which the patient did not mention. Choice D is incorrect as chronic sorrow is typically associated with ongoing feelings of sadness and longing, which are not explicitly expressed by the patient.

Question 7 of 9

When caring for a patient with a pulmonary artery (PA) pressure catheter, the nurse observes that the PA waveform indicates that the catheter is in the wedged position. Which action should the nurse take next?

Correct Answer: C

Rationale: The correct answer is C: Notify the health care provider. When the PA waveform indicates the catheter is in the wedged position, it means the catheter tip is in the pulmonary artery, potentially causing complications. The nurse should notify the healthcare provider immediately to assess and reposition the catheter to prevent further issues. Zero balancing the transducer (A) or activating the fast flush system (B) are not appropriate actions for this situation. Deflating and reinflating the PA balloon (D) could exacerbate the issue and should only be done under the guidance of the healthcare provider.

Question 8 of 9

The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?

Correct Answer: A

Rationale: The correct answer is A: Remove the patient's rings first. This is crucial to prevent constriction and swelling due to potential allergic reactions or inflammation from bee stings. Removing rings allows for proper circulation and prevents complications like compartment syndrome. Ice packs (B) can be applied after removing the rings to reduce swelling. Calamine lotion (C) can provide relief for itching but is not as urgent as ring removal. Diphenhydramine (D) can be given later for systemic allergic reactions but should not take precedence over removing the rings.

Question 9 of 9

A nurse decides to seek certification in critical care nursing. What is the most important benefit for the individual nurse in becoming certified in a specialty?

Correct Answer: C

Rationale: The correct answer is C because obtaining certification in critical care nursing demonstrates the nurse's personal expertise in the specialty. Certification confirms the nurse's advanced knowledge and skills, enhancing professional credibility and potential for career advancement. This choice focuses on the individual nurse's competency and dedication to the specialty. Incorrect choices: A: Salary increase is not the primary benefit of certification, although it may be a potential outcome. B: Certification is often preferred but not always required to work in critical care. D: Employers may encourage certification, but it is not always mandated.

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