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Which of the following devices is best suited to deliver 65 % oxygen to a patient who is spontaneously breathing?
- A. Face mask with non-rebreathing reservoir
- B. Low-flow nasal cannula
- C. Simple face mask
- D. Venturi mask
Correct Answer: D
Rationale: The Venturi mask is the best choice for delivering 65% oxygen because it allows precise oxygen concentration delivery through adjustable venturi valves. This device ensures consistent oxygen levels even during variations in patient breathing patterns. Face mask with non-rebreathing reservoir (A) delivers higher oxygen concentrations, low-flow nasal cannula (B) is not suitable for precise oxygen delivery, and simple face mask (C) may not provide the desired oxygen concentration.
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A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse should provide the patient with what explanation?
- A. “I’m going to contact the pharmacist to see if you can take this medication by mouth.”
- B. “This injection is being given to prevent blood clots fr om forming.”
- C. “This medication will dissolve any blood clots you migabhirtb .gcoemt./”te st
- D. “I will contact your primary care provide to discuss wh y you are getting this medication.” t
Correct Answer: B
Rationale: The correct answer is B: “This injection is being given to prevent blood clots from forming.” Enoxaparin is an anticoagulant used to prevent blood clots. It is administered through injection, not orally (A). Enoxaparin does not dissolve existing blood clots (C). Contacting the primary care provider to discuss the medication is not necessary in this scenario (D). The correct choice emphasizes the purpose of enoxaparin in preventing new blood clots.
What nonpharmacological approaches to pain and/or anxie ty may best meet the needs of critically ill patients? (Select all that apply.)
- A. Anaerobic exercise
- B. Art therapy
- C. Guided imagery
- D. Music therapy
Correct Answer: B
Rationale: The correct answer is B: Art therapy. Art therapy can help critically ill patients express emotions, reduce anxiety, and cope with pain in a nonverbal way. It provides a creative outlet for self-expression and can improve overall well-being. Anaerobic exercise (A) may not be suitable for critically ill patients due to physical limitations. Guided imagery (C) may not be effective for all patients and requires a certain level of cognitive ability. Music therapy (D) can be beneficial, but art therapy is specifically known for its effectiveness in addressing emotional and psychological needs in critically ill patients.
A patient is admitted to the hospital with multiple trauma aabnirdb .ceoxmte/tensst ive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vas cular resistance of 3000 dynes/sec/cm5, and a hematocrit of 20%. The nurse anticip ates administration of which the following therapies or medications?
- A. Blood transfusion
- B. Furosemide
- C. Dobutamine infusion
- D. Dopamine hydrochloride infusion
Correct Answer: C
Rationale: The correct answer is C: Dobutamine infusion. In this scenario, the patient is experiencing hypovolemic shock due to significant blood loss, resulting in low blood pressure, tachycardia, and low cardiac output. Dobutamine is a positive inotropic agent that increases cardiac contractility and output, helping to improve tissue perfusion.
Blood transfusion (A) is a common intervention for hypovolemic shock, but in this case, the patient's hematocrit is low, indicating dilutional anemia rather than acute blood loss, so addressing the cardiac output is more urgent. Furosemide (B) is a diuretic that would exacerbate the hypovolemia and worsen the patient's condition. Dopamine (D) is a vasopressor that primarily increases blood pressure, but in this case, the patient's low cardiac output is the main concern, making dobutamine a more appropriate choice.
Family assessment can be challenging and each nurse may obtain additional information regarding family structure and dynamics. What is the best way to share this information from shift to shift?
- A. Create an informal family information sheet that is kept on the bedside clipboard. That way, everyone can review it quickly when needed .
- B. Develop a standardized reporting form for family infora mbir ab. tc io om n/ te thst a t is incorporated into the patient’s medical record and updated as neede d.
- C. Require that the charge nurse have a detailed list of inf ormation about each patient and family member. Thus, someone on the unit is always knowledgeable about potential issues.
- D. Try to remember to discuss family structure and dynamics as part of the change-of-shift report.
Correct Answer: B
Rationale: The correct answer is B because developing a standardized reporting form for family information that is incorporated into the patient's medical record ensures consistency and accuracy in sharing vital details about family structure and dynamics from shift to shift. This method allows all healthcare providers to access the information easily and update it as needed, promoting continuity of care and comprehensive understanding of the family's needs.
Choices A, C, and D are incorrect because:
A: Creating an informal family information sheet may lead to inconsistencies in the information shared among healthcare providers and may not be updated regularly.
C: Requiring only the charge nurse to have detailed information may result in information silos and lack of accessibility for all team members.
D: Discussing family dynamics as part of the change-of-shift report may lead to important details being missed or forgotten, compromising the quality of care provided.
During a client assessment, the client says, 'I can't walk very well.' Which action should the nurse implement first?
- A. Predict the likelihood of the outcome.
- B. Consider alternatives.
- C. Choose the most successful approach.
- D. Identify the problem.
Correct Answer: D
Rationale: The correct answer is D: Identify the problem. This is the first action the nurse should take in the nursing process as it helps in understanding the client's issue. By identifying the problem, the nurse can gather more information through further assessment to determine the underlying cause of the client's difficulty in walking. This step is crucial for developing an effective care plan and interventions.
A: Predict the likelihood of the outcome - This choice is not appropriate as predicting the outcome should come after identifying the problem and implementing interventions.
B: Consider alternatives - While considering alternatives is important in the decision-making process, it is not the immediate action needed in this scenario.
C: Choose the most successful approach - This choice is premature as the nurse needs to first identify the problem before determining the most successful approach.