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 ["B","C","E"]

Explanation

A. Crackles are more commonly associated with left ventricular failure, which leads to pulmonary congestion.

B. Hepatomegaly, or an enlarged liver, is a sign of right ventricular failure due to blood backing up in the systemic circulation.

C. Jugular venous distention is a classic sign of right ventricular failure as blood accumulates in the venous system.

D. Orthopnea, or difficulty breathing while lying down, is more indicative of left ventricular failure.

E. Peripheral edema is a hallmark of right ventricular failure, resulting from increased venous pressure.

A. Coronary artery bypass graft surgery B. Radiofrequency catheter ablation C. Implantable cardioverter-defibrillator placement D. Circulatory assist device

Correct Answer is A

Explanation

A. Coronary artery bypass graft (CABG) surgery is typically recommended for patients with significant occlusion of the left main coronary artery, as it effectively restores blood flow to the heart muscle by bypassing the blocked artery.

B. Radiofrequency catheter ablation is used to treat arrhythmias, not coronary artery occlusions.

C. Implantable cardioverter-defibrillator (ICD) placement is for managing life-threatening arrhythmias, not directly for treating coronary artery blockages.

D. A circulatory assist device is used in severe cases of heart failure, but it does not address the underlying issue of coronary artery occlusion.

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.

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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?

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Naxlex Comprehensive Predictor Exams

Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

The patient presents to the ED with severe chest discomfort. A cardiac catheterization and angiography shows an 90% occlusion of the left main coronary artery. Which procedure will be most likely performed on this patient?

Correct Answer is A

Explanation

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.

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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?

A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as the cause of the client's low potassium level?