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What is the most important nursing intervention for patien ts who receive neuromuscular blocking agents?
- A. Administer sedatives in conjunction with the neuromu as bc iu rbl .a cor m b /tl eo sc t king agents.
- B. Assess neurological status every 30 minutes.
- C. Avoid interaction with the patient, because he or she won’t be able to hear.
- D. Restrain the patient to avoid self-extubation.
Correct Answer: B
Rationale: The correct answer is B: Assess neurological status every 30 minutes. This intervention is crucial for patients receiving neuromuscular blocking agents to monitor for any adverse effects such as respiratory depression or paralysis. Regular assessments help ensure early detection of complications and prompt intervention.
A: Administering sedatives in conjunction with neuromuscular blocking agents can potentiate respiratory depression and lead to respiratory compromise.
C: Avoiding interaction with the patient is not appropriate as communication and patient interaction are important aspects of nursing care.
D: Restraint should be avoided as it can increase the risk of complications such as pressure ulcers, anxiety, and decreased respiratory function.
Overall, regular neurological assessments are essential for ensuring patient safety and prompt intervention in case of any complications.
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A 53-year-old, 80-kg patient is admitted to the cardiac sur gical intensive care unit after cardiac surgery with the following arterial blood gas (ABG ) levels. What is the nurse’s interpretation of these values? pH 7.4 PaCO 40 mm Hg Bicarbonate 24 mEq/L PaO 95 mm Hg O saturation 97% Respirations 20 breaths per minute
- A. Compensated metabolic acidosis
- B. Metabolic alkalosis
- C. Normal ABG values
- D. Respiratory acidosis
Correct Answer: C
Rationale: The correct interpretation is C: Normal ABG values.
1. pH is within the normal range of 7.35-7.45.
2. PaCO2 is 40 mm Hg, within the normal range of 35-45 mm Hg.
3. Bicarbonate is 24 mEq/L, within the normal range of 22-26 mEq/L.
4. PaO2 is 95 mm Hg, within the normal range of 80-100 mm Hg.
5. Oxygen saturation is 97%, which is normal.
6. Respirations are also within the normal range at 20 breaths per minute.
Overall, all values fall within the normal range, indicating a well-maintained acid-base balance. Other choices are incorrect because there are no abnormalities that would suggest compensated metabolic acidosis, metabolic alkalosis, or respiratory acidosis based on the given ABG values.
Which findings have been reported in the literature as benefits of allowing family to be present during resuscitation and invasive procedures? (Selaebcirtb a.clolm t/hteastt apply.)
- A. Families benefit by witnessing that everything possible was done.
- B. Families report reduced anxiety and fear about what is being done to the patient.
- C. Presence encourages family members to seek litigation for improper care.
- D. Presence reduces nurses’ involvement in explaining th ings to the family.
Correct Answer: A
Rationale: Step 1: Families benefit by witnessing that everything possible was done during resuscitation and invasive procedures.
Step 2: This reassures families that healthcare providers are doing their best to save the patient.
Step 3: It can provide closure and comfort to families knowing that all efforts were made.
Step 4: This transparency can also help in the grieving process for families.
Summary: Choice A is correct because it highlights the emotional and psychological benefits for families. Choices B, C, and D are incorrect as they do not align with the positive impacts of allowing family presence during resuscitation and invasive procedures.
The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse sh ould provide instruction?
- A. “If you get the pneumococcal vaccine, you’ll never get pneumonia again.”
- B. “It is important for you to get an annual influenza shot to reduce your risk of pneumonia.”
- C. “Stay away from cold, drafty places because that incre ases your risk of pneumonia when you get home.”
- D. “Since you have been treated for pneumonia, you now have immunity from getting it in the future.”
Correct Answer: B
Rationale: Step 1: Influenza can lead to pneumonia as a complication, so getting an annual flu shot can reduce the risk of pneumonia.
Step 2: Providing education on the importance of prevention aligns with discharge teaching goals.
Step 3: Option A is incorrect as the pneumococcal vaccine doesn't guarantee immunity from all causes of pneumonia.
Step 4: Option C is incorrect as cold or drafty places do not directly cause pneumonia.
Step 5: Option D is incorrect as having pneumonia once does not confer permanent immunity.
The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education?
- A. The RN increases the FIO2 to 100% before suctioning.
- B. The RN secures a bite block in place using adhesive tape.
- C. The RN asks for assistance to reposition the endotracheal tube.
- D. The RN positions the patient with the head of the bed at 10 degrees.
Correct Answer: D
Rationale: The correct answer is D because positioning the patient with the head of the bed at 10 degrees is incorrect for a patient receiving mechanical ventilation. The optimal position for such patients is to elevate the head of the bed to 30-45 degrees to prevent aspiration and improve oxygenation. Option A is incorrect as increasing FIO2 before suctioning is appropriate to ensure adequate oxygenation. Option B is incorrect as securing a bite block in place using adhesive tape is a standard practice to prevent the patient from biting on the endotracheal tube. Option C is incorrect as asking for assistance to reposition the endotracheal tube shows the RN is aware of the importance of proper placement to ensure effective ventilation.
When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87°F (30.6°C), which assessment indicates that the nurse should discontinue active rewarming?
- A. The patient begins to shiver.
- B. The BP decreases to 86/42 mm Hg.
- C. The patient develops atrial fibrillation.
- D. The core temperature is 94°F (34.4°C).
Correct Answer: D
Rationale: The correct answer is D. When rewarming a hypothermic patient, the goal is to gradually increase their core temperature. A core temperature of 94°F (34.4°C) is still below the normal range, but it indicates that the rewarming process is working. Shivering (A) is a normal response to rewarming. A decrease in blood pressure (B) may be expected due to peripheral vasodilation during rewarming. Developing atrial fibrillation (C) may be a concern but does not necessarily indicate that rewarming should be discontinued. Therefore, choice D is correct as it signifies progress in the rewarming process.