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NEW QUESTION # 169
An Asian patient in the ICU with a brain injury has a family who insists on traditional healing practices along with modern medicine. What is the BEST approach for the nurse to take in this situation?
Answer: D
Explanation:
Collaboration with the healthcare team and the family to understand and possibly integrate the practices shows respect for the family's beliefs while also ensuring the safety of the patient. Simply refusing the request may come off as dismissive of their beliefs, while allowing the family to proceed without supervision can risk the patient's safety. Telling the family that only modern medicine is allowed in the ICU is also dismissive and lacks cultural sensitivity in a situation where their request may be able to be accommodated.
NEW QUESTION # 170
A patient lying on the left side in Trendelenburg position is in the correct position for postural drainage of which of the following lobes of the lungs?
Answer: D
Explanation:
For postural drainage of the right lower lobe, the patient should be positioned on their left side in the Trendelenburg position. This positioning utilizes gravity to facilitate the drainage of secretions from the right lower lobe of the lungs. In the Trendelenburg position, the body is laid flat on the back with the feet higher than the head, which helps drain the lower lobes effectively.References: = CCRN Exam Handbook, page 22
NEW QUESTION # 171
The critical care nurse is busy caring for a patient during a night shift and is unavailable to provide her other patient's evening bath until 0300. The unit has a nighttime sleep protocol in which patient interaction is limited between 0100 and 0500.
Which action taken by the nurse is best?
Answer: D
Explanation:
Lack of sleep is a huge problem for critically ill patients for many reasons, and a nighttime sleep protocol is a very helpful tool to minimize sleep disturbances.
A non-essential care intervention, such as a bath, should not be provided during this block of time.
Providing the bath (or a revised version of a bath), but allowing the patient to sleep in later, will not be an effective intervention, as other members of the healthcare team will need to perform interventions after the scheduled sleep time is over. The nurse should still attempt to provide the bath once the scheduled sleep period is over as close to 0500 as possible.
NEW QUESTION # 172
responding well to a relatively new treatment protocol; however, the nurse is aware that some of her colleagues believe there may be long-term safety risks associated with the new protocol. The nurse is assigned this patient and does not have time to review research on the new protocol prior to providing care. Which action by the nurse is BEST?
Answer: B
Explanation:
The nurse should ensure that their clinical knowledge is as up to date as possible. If the nurse is placed in a situation where reviewing the research is impractical and a new technique is being used, the nurse should prioritize learning about the new technique or protocol as soon as possible. A lack of clinical knowledge is not necessarily grounds for discontinuing something that is having a positive effect and the treatment should not be discontinued; however, the nurse must prioritize reviewing the research on it as soon as they can. Ask the patient about following the new protocol is not appropriate until the nurse is better able to inform the patient about the science underlying its use.
NEW QUESTION # 173
An acute pulmonary embolism (PE) is MOST LIKELY to cause which of the following acid-base disorders?
Answer: A
Explanation:
Explanation Detail
An acute PE is a clinical condition that causes respiratory alkalosis, a condition in which the body's pH is elevated above 7.45 (alkaline), CO2 is low (below 35 mm Hg), and HCO3 is low (metabolic component).
There is an excessive amount of ventilation (alveolar hyperventilation) and removal of CO2 from the body.
Management of respiratory alkalosis is directed at treating the underlying cause, improving oxygenation and ventilation (decreasing excessive ventilation), improving cardiovascular function, and preventing reembolization. Supplemental oxygen therapy is often very effective in relieving hypoxemia associated with PE.
NEW QUESTION # 174
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