What is the nurse’s priority intervention when a terminally ill patient reports severe breakthrough pain?

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Question 1 of 5

What is the nurse’s priority intervention when a terminally ill patient reports severe breakthrough pain?

Correct Answer: B

Rationale: The correct answer is B: Administer a prescribed PRN opioid analgesic. This is the priority intervention because severe breakthrough pain requires immediate relief, and opioids are the most effective for managing severe pain in terminally ill patients. Warm compresses (A) may provide some comfort but do not address the underlying pain. Reassessing pain after 2 hours (C) delays necessary relief. Distraction techniques (D) are not appropriate for severe breakthrough pain as they do not directly address the pain itself. Administering the prescribed opioid analgesic promptly is crucial for providing timely and effective pain management in this situation.

Question 2 of 5

Her urine output for the past 2 hours totaled only 40 mL. She arrived from s urgery to repair an aortic aneurysm 4 hours ago and remains on mechanical ventilation. In the past 2 hours, her heart rate has increased from 80 to 100 beats per minute and he r blood pressure has decreased from 128/82 to 100/70 mm Hg. She is being given an infusaiboirnb .coofm n/toesrtm al saline at 100 mL per hour. Her right atrial pressure through the subclavian cen tral line is low at 3 mm Hg. Her urine is concentrated. Her BUN and creatinine levels have been stable and in normal range. Her abdominal dressing is dry with no indication of bleeding. My assessment suggests that Mrs. P. is hypovolemic and I would like you to consider in creasing her fluids or giving her a fluid challenge. Using the SBAR model for communication, the information the nurse gives about the patient’s history and vital signs is appropriate fo r what part of the model?

Correct Answer: C

Rationale: The correct answer is C: Assessment. In the SBAR communication model, the nurse's information about the patient's history and vital signs falls under the Assessment component. This is because the nurse is providing a detailed evaluation of the patient's current condition based on objective data such as urine output, heart rate, blood pressure, and other key indicators. The nurse is analyzing the situation and forming a judgment that the patient is hypovolemic, indicating a fluid deficit. This assessment is crucial for informing further actions or interventions, such as increasing fluids or providing a fluid challenge. Summary of other choices: A: Situation - This choice would refer to a brief summary of the current situation without detailed analysis or interpretation. B: Background - This choice would involve providing relevant background information about the patient, such as medical history or recent procedures, but not the current assessment of the patient's condition. D: Recommendation - This choice would involve suggesting a course of action or treatment based on the assessment, which comes after

Question 3 of 5

Which of the following statements describes the core conc ept of the synergy model of practice?

Correct Answer: D

Rationale: Rationale: D is correct because the synergy model focuses on individualized care based on patients' unique needs. This model emphasizes tailoring nursing competencies to address these needs, promoting holistic care. A is incorrect as certification is not a requirement. B involves family inclusion but does not capture the core concept. C mentions collaboration but does not specifically address individualized care.

Question 4 of 5

Which scenarios contribute to effective handoff communicaabitribo.cno ma/tte csth ange of shift? (Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A because it demonstrates effective handoff communication by involving key stakeholders (nephrology consultant physician), requesting specific patient updates, and collaborating on patient care tasks (placing a central line). This scenario promotes continuity of care and ensures important information is shared. Explanation for why other choices are incorrect: B: High noise level disrupts communication and can lead to errors or omissions in handoff information. C: While using a standardized checklist can be beneficial, it alone does not guarantee effective communication if not utilized properly or if key information is missed. D: Conducting reports at the patient's bedside is beneficial for patient involvement but may not address the need for involving relevant healthcare providers like the consultant physician in the handoff process.

Question 5 of 5

Sleep often is disrupted for critically ill patients. Which nu rsing intervention is most appropriate to promote sleep and rest?

Correct Answer: A

Rationale: The correct answer is A: Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals. This is the most appropriate intervention as medication timings can significantly impact sleep patterns of critically ill patients. Adjusting medication times can help synchronize rest periods, promoting uninterrupted sleep. Choice B is incorrect as encouraging constant conversation can disrupt sleep. Choice C is incorrect as the television noise can be stimulating and hinder rest. Choice D is incorrect as leaving the lights on can disrupt the patient's circadian rhythm and negatively impact sleep quality.

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