While close family members are visiting, a patient has a respiratory arrest, and resuscitation is started. Which action by the nurse is best?

Take the family members quickly out of the patient room and remain with them.

Tell the family members that watching the resuscitation will be very stressful.

Ask family members if they wish to remain in the room during the resuscitation.

Assign a staff member to wait with family members just outside the patient room.

Answer and Explanation

The Correct Answer is C

A. Quickly removing the family members may add to their distress and does not respect their right to decide.

B. Telling them it will be stressful assumes their reaction without giving them a choice.

C. Allowing the family members to choose whether to stay respects their autonomy and can provide comfort during a difficult time. It is also in line with current best practices for family presence during resuscitation.

D. Assigning a staff member to wait outside is appropriate but should be done after offering the family the option to stay in the room.

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Correct Answer is A

Explanation

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.

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. Furosemide B. Echocardiogram C. Aspirin D. Losartan E. Cardiac catheterization F. Chest X-ray

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

Explanation

Furosemide: Furosemide is a diuretic that is commonly used to manage fluid overload in patients with heart failure. The patient has significant pitting edema, increasing dyspnea, and elevated BNP levels, indicating worsening heart failure. Administering furosemide is a high priority to reduce fluid overload and relieve symptoms.

Echocardiogram: An echocardiogram can provide valuable information about heart function.

Aspirin: Aspirin is typically used for its antiplatelet effects in conditions like coronary artery disease. It is not essential for managing acute symptoms of heart failure. The patient’s primary issue is fluid overload rather than a clotting concern.

Losartan: Losartan, an angiotensin II receptor blocker (ARB), is commonly used in the management of chronic heart failure to reduce afterload and prevent further cardiac remodeling. It is essential as part of the long-term management plan for heart failure.

Cardiac catheterization: Cardiac catheterization is an invasive procedure typically used to assess coronary artery disease or for interventional procedures. It is not indicated for the acute management of heart failure symptoms and could pose unnecessary risks in this context.

Chest X-ray: A chest X-ray is essential to assess the extent of pulmonary congestion and rule out other causes of respiratory distress, such as pneumonia or pleural effusion, which are important in managing a patient with worsening heart failure.

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While close family members are visiting, a patient has a respiratory arrest, and resuscitation is started. Which action by the nurse is best?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

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.

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

Explanation

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?

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

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

The patient is admitted with a suspected acute myocardial infarction (AMI). In assessing the 12-lead electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process of a myocardial infarction (MI)?

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?

A patient is having a cardiac evaluation to assess for possible heart failure and valvular disease. Which study best identifies heart function and measures the size of the cardiac chambers?