C.
Intravenous (IV) via central line
✓
A.
Apply mitts or restraints immediately
✓
B.
Distract and redirect the patient with a preferred activity
✓
C.
Yell at the patient to stop
✓
A.
Encourage them to relive the entire memory in detail
✓
B.
Use grounding techniques to help them orient to the present moment
✓
C.
Tell them the memory is not real
✓
D.
Change the subject abruptly
✓
D.
Continuous compressions
✓
A.
Administer oral insulin
✓
B.
Administer IV dextrose (if available and trained) or glucagon IM
✓
C.
Provide a sugar-free drink
✓
A.
Discussing patient details in public areas
✓
B.
Leaving the patient's room door open during care
✓
C.
Knocking before entering and closing the door during care
✓
D.
Using the patient's full name in casual conversation
✓
A.
Suction for prolonged periods (e.g., over 30 seconds)
✓
B.
Apply suction while inserting the catheter
✓
C.
Limit suction passes to 10-15 seconds and hyperoxygenate before/after
✓
D.
Use sterile technique only for catheter insertion, not for withdrawal
✓
A.
Override the directive for their well-being
✓
B.
Respect the patient's wishes as stated in the advance directive
✓
C.
Ask the family to decide, regardless of the directive
✓
D.
Provide nutrition against their wishes
✓
C.
Blood pressure and heart rate
✓
A.
Numeric rating scale (NRS)
✓
B.
Wong-Baker FACES pain rating scale or FLACC scale (for non-verbal)
✓
C.
Verbal descriptor scale
✓
D.
Visual analog scale (VAS)
✓
A.
Disconnect the IV and restart it
✓
B.
Increase the infusion rate
✓
C.
Check the IV line for kinks, clamps, or infiltration
✓
D.
Administer a bolus of IV fluid
✓
C.
Non-maleficence (do no harm)
✓
D.
Beneficence (do good)
✓
A.
Administer a sedative without physician order
✓
B.
Assess for potential causes (e.g., pain, tube dislodgement, anxiety) and notify physician
✓
C.
Silence the alarms and leave the room
✓
D.
Increase the ventilator settings
✓
A.
Leave the bed in the highest position
✓
B.
Keep pathways clear, use non-slip socks, and ensure adequate lighting
✓
C.
Apply restraints at all times
✓
D.
Allow the patient to wander freely
✓
C.
The patient's self-report
✓
A.
Acute Stress Disorder
✓
C.
Post-Traumatic Stress Disorder (PTSD)
✓
D.
Generalized Anxiety Disorder
✓
