ANSWERS 2024 LATEST VERSION GRADED A+
2. The cri�cal care nurse recognizes that an ideal plan for caregiver involvement includes
A. allowing caregivers at the bedside at preset, brief intervals.
B. a caregiver at the bedside at all �mes.
C. restric�on of visi�ng in the ICU because the environment is overwhelming to caregivers.
D. an individually devised plan to involve caregivers with care and comfort measures. - ansD. An
individually devised plan to involve caregivers with care and comfort measures.
Ra�onale: An individualized plan of care should be developed for each pa�ent and the caregivers.
Caregivers should be allowed to assist with care and comfort measures in the ICU if desired.
A client receiving a transfusion of packed red blood cells begins to vomit. The client's blood pressure is
90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8 ° F orally from a
baseline of 99.2 ° F. The nurse determines that the client may be experiencing which complica�on of a
blood transfusion?
A. Sep�cemia
B. Hyperkalemia
C. Circulatory overload
D. Delayed transfusion reac�on - ansA. Sep�cemia
occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever,
vomi�ng, diarrhea, hypotension, and the development of shock.
The intensive care unit (ICU) nurse educator will determine that teaching about arterial pressure
monitoring for a new staff nurse has been effec�ve when the nurse
a. balances and calibrates the monitoring equipment every 2 hours.