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A patient’s vital signs are pulse 87, respirations 24, BP of 128/64 mm Hg, and cardiac output is 4.7 L/min. The patient’s stroke volume is ______ mL. (Round to the nearest whole number.)
- A. 54
- B. 64
- C. 74
- D. 84
Correct Answer: A
Rationale: The stroke volume is calculated by dividing the cardiac output by the heart rate. Given the cardiac output of 4.7 L/min and a heart rate of 87 bpm, the stroke volume is 54 mL (4700 mL/87 bpm ≈ 54 mL). Therefore, choice A (54) is the correct answer. Choices B, C, and D are incorrect as they do not match the calculated stroke volume based on the provided cardiac output and heart rate.
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After coronary artery bypass graft surgery a patient is transported to the surgical intensive care unit at noon and placed on mechanical ventilation. How sh ould the nurse interpret the patient’s initial arterial blood gas levels? pH 7.31 PaCO 48 mm Hg Bicarbonate 22 mEq/L PaO 115 mm Hg O saturation 99%
- A. Normal arterial blood gas levels with a high oxygen le vel
- B. Partly compensated respiratory acidosis, normal oxygen
- C. Uncompensated metabolic acidosis with high oxygen laebvirbe.lcso m/test
- D. Uncompensated respiratory acidosis; hyperoxygenated
Correct Answer: B
Rationale: The correct answer is B: Partly compensated respiratory acidosis, normal oxygen. The pH of 7.31 indicates acidosis, the PaCO2 of 48 mm Hg shows respiratory acidosis, and the bicarbonate level of 22 mEq/L is slightly elevated, indicating the kidneys are compensating. The PaO2 of 115 mm Hg and oxygen saturation of 99% are normal, ruling out hypoxemia. Therefore, the patient is experiencing partly compensated respiratory acidosis.
A: Normal arterial blood gas levels with a high oxygen level - Incorrect. The pH is low, indicating acidosis, which is not normal.
C: Uncompensated metabolic acidosis with high oxygen level - Incorrect. Metabolic acidosis would have a primary issue with bicarbonate levels, which is not the case here.
D: Uncompensated respiratory acidosis; hyperoxygenated - Incorrect. The oxygen levels are normal, ruling out hyperoxygenation.
The primary health care provider writes an order to discon tinue a patient’s left radial arterial line. When discontinuing the patient’s invasive line, what is the priority nursing action?
- A. Apply an air occlusion dressing to insertion site.
- B. Apply pressure to the insertion site for 5 minutes.
- C. Elevate the affected limb on pillows for 24 hours.
- D. Keep the patient’s wrist in a neutral position.
Correct Answer: B
Rationale: The correct answer is B: Apply pressure to the insertion site for 5 minutes. This is the priority nursing action because it helps prevent bleeding and hematoma formation after removing the arterial line. Applying pressure for 5 minutes allows for adequate hemostasis.
A: Applying an air occlusion dressing to the insertion site is not the priority action. It does not address the immediate need to control bleeding.
C: Elevating the affected limb on pillows for 24 hours is not necessary and does not address the immediate need for hemostasis.
D: Keeping the patient's wrist in a neutral position is not the priority action when discontinuing an arterial line. It does not address the need for hemostasis and preventing bleeding.
The nurse is caring for a terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be most appropriate?
- A. Suction the patient.
- B. Administer oxygen via face mask.
- C. Place the patient in a high Fowler’s position.
- D. Document the respirations as Cheyne-Stokes.
Correct Answer: D
Rationale: The correct answer is D because the patient is exhibiting Cheyne-Stokes breathing pattern characterized by periods of apnea followed by deep and rapid breathing. The nurse should document this pattern accurately. Option A is incorrect as suctioning is not indicated. Option B may worsen the respiratory pattern. Option C is not specifically related to addressing the breathing pattern.
Which patient should the nurse refer for hospice care?
- A. A 60-year-old with lymphoma whose children are unable to discuss issues related to dying.
- B. A 72-year-old with chronic severe pain due to spinal arthritis and vertebral collapse.
- C. A 28-year-old with AIDS-related dementia who needs palliative care and pain management.
- D. A 56-year-old with advanced liver failure whose family members can no longer provide care in the home.
Correct Answer: C
Rationale: The correct answer is C because the patient with AIDS-related dementia requires palliative care and pain management, which are key components of hospice care. This patient is likely in the terminal stage of their illness and would benefit from the comprehensive support provided by hospice services.
Choice A is incorrect because the patient's children's inability to discuss dying issues does not necessarily indicate a need for hospice care. Choice B is incorrect as chronic severe pain due to spinal arthritis is not a sole criterion for hospice referral. Choice D is incorrect as advanced liver failure alone does not automatically qualify a patient for hospice care.
The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
- A. A nystagmus on the left.
- B. Exophthalmos on the right.
- C. Ptosis on the left eyelid.
- D. Astigmatism on the right.
Correct Answer: C
Rationale: The correct answer is C: Ptosis on the left eyelid. Ptosis refers to drooping of the eyelid, which is a common condition in older adults. In this scenario, the nurse should document the finding as ptosis on the left eyelid because the client's left upper eyelid is drooping, covering more of the iris than the right eyelid.
Explanation: Nystagmus (A) is an involuntary eye movement, not related to eyelid drooping. Exophthalmos (B) is the protrusion of the eyeball and not relevant to this scenario. Astigmatism (D) refers to a refractive error of the eye and does not cause eyelid drooping. Therefore, the correct choice is C as it accurately describes the client's condition.