A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?
Neurology unit supervisor.
Nurse case manager.
Adult nurse practitioner.
Risk management nurse.
The Correct Answer is B
Rationale
A. This role oversees the neurology unit but may not be directly involved in ICU care coordination, which requires a focus on acute management and transition to rehabilitation.
B. Nurse case managers are skilled in coordinating care for patients with complex conditions, ensuring continuity of care, and facilitating communication among healthcare providers and the client's family.
C. While an NP may be involved in direct patient care, their role is more focused on clinical management rather than comprehensive care coordination across different disciplines.
D. This role deals with patient safety and risk reduction but is not primarily responsible for coordinating care for a specific patient's acute medical needs and rehabilitation planning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Rationale
A. This involves visually inspecting the chest to ensure both sides rise and fall equally during ventilation. Symmetrical chest movement suggests that both lungs are being adequately ventilated.
B. Auscultation involves listening with a stethoscope over the chest to confirm the presence of breath sounds in both lung fields. Bilateral breath sounds indicate that the ETT is correctly positioned in the trachea, allowing air to reach both lungs.
C. A chest x-ray provides a definitive confirmation of the ETT placement in relation to the trachea and lungs. It allows visualization of the tube's position relative to anatomical landmarks, such as the carina, which helps ensure proper placement.
This involves checking the markings on the ETT tube to ensure it is inserted to the correct depth. Typically, the ETT should be positioned with its tip approximately 2 to 4 cm above the carina, which corresponds to the 22-26 cm mark at the teeth line in adults. However, it does not confirm correct placement.
E. Capillary refill is a measure of peripheral perfusion and is unrelated to ETT placement. It assesses circulatory status by pressing on a nail bed and observing the time it takes for color to return. It does not provide information about ETT placement.
Correct Answer is B
Explanation
Rationale
A. Applying ice or a warm compress without assessing the site could potentially worsen any underlying issue.
B. The appropriate intervention would be to discontinue the IV site after ensuring a new access is established. This is because continuing to use a painful IV site can lead to complications such as infiltration or phlebitis.
C. Redressing the site without assessment does not address the client's complaint of pain.
D. Checking the medical record provides information about when the IV was inserted, which can be important for assessing the site's viability and expected duration. However, it doesn't address the immediate concern of the client's pain at the site or refusal of a flush.
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