A patient who has been in the intensive care unit for 4 days has disturbed sensory perception from sleep deprivation. Which action should the nurse include in the plan of care?

Cluster nursing activities so that the patient has uninterrupted rest periods.

Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps.

Administer sedatives or opioids at bedtime to promote sleep.

Eliminate assessments between 2200 and 0600 to allow uninterrupted sleep

Answer and Explanation

The Correct Answer is A

A. Clustering nursing activities helps to minimize interruptions, allowing the patient to have longer periods of uninterrupted rest, which is essential for recovery and reducing sensory disturbances from sleep deprivation.

B. Silencing alarms could compromise patient safety and is not recommended.

C. Administering sedatives or opioids should be done cautiously and is not a first-line approach for promoting sleep, especially if non-pharmacological methods can be effective.

D. While reducing nighttime assessments may help with sleep, it is not always feasible and should be balanced with the need for monitoring the patient’s condition.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Administer furosemide IV: Furosemide is a diuretic used to manage fluid overload, which is not the primary concern in this scenario. The client presents with chest pain suggestive of a cardiac event, so other interventions should take priority.

Prepare the client for intubation: Intubation is not indicated at this stage as the patient is conscious, has a respiratory rate of 18/min, and there is no immediate indication of airway compromise. Oxygen therapy is more appropriate.

Obtain the client’s full family history: While obtaining a full family history is important for a comprehensive assessment, it is not a high priority in the acute management of this client who presents with symptoms suggestive of a myocardial infarction (MI).

Administer O2 to maintain oxygen saturation greater than 90%: The client’s oxygen saturation is 88%, which is below the desired level. Administering oxygen to maintain saturation greater than 90% is a high-priority intervention to improve oxygenation.

Apply continuous ECG monitoring: Continuous ECG monitoring is essential in this scenario to monitor for arrhythmias and assess for ongoing ischemia, given the client’s chest pain, irregular pulse, and the high likelihood of an acute coronary syndrome.

Obtain vascular access: Establishing vascular access is a high priority to ensure the ability to administer medications, fluids, and for potential blood draws, especially in an emergency setting where rapid intervention may be necessary.

A. "The catheter will be in position until the heart has a chance to heal." B. The catheter will allow the provider to better manage fluid therapy." C. "The catheter tip comes to rest inside my brother's left ventricle." D. "The catheter will provide multiple IV sites to give intravenous fluid."

Correct Answer is B

Explanation

A. While a CVP catheter might be in place for an extended period, its purpose is not directly related to heart healing.

B. The CVP catheter is used to monitor central venous pressure, which helps guide fluid management and assess right heart function.

C. The CVP catheter does not extend into the left ventricle; it is typically positioned in the superior vena cava or right atrium.

D. The CVP catheter may have multiple lumens for administering fluids, but its primary purpose is hemodynamic monitoring, not just providing IV access.

View Question and Answer

A nurse is caring for a client who has heart failure.

<div id="exhibits">Exhibits</div>

For each potential provider's prescription, click to specify if the prescription is essential (high priority) non-essential (low priority) or contraindicated(unrelated) for the client.

View Question and Answer

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A patient who has been in the intensive care unit for 4 days has disturbed sensory perception from sleep deprivation. Which action should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

The nurse is educating a patient's family member about a central venous pressure catheter (CVP). Which statement by the family member best indicates understanding of the purpose of the CVP?

Correct Answer is B

Explanation

Which laboratory test result will the nurse review to determine the effects of therapy for a patient being treated for heart failure?

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The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. Which laboratory test result should be most helpful in indicating myocardial infarction?

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The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care?

A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?

A nurse is caring for a client who has heart failure. <div id="exhibits">Exhibits</div> For each potential provider's prescription, click to specify if the prescription is essential (high priority) non-essential (low priority) or contraindicated(unrelated) for the client.

A nurse is teaching a class about organ donation. Which of the following information should the nurse include?