Nokea
When assessing the patient for hypoxemia, the nurse recognizes what as an early sign of the effect of hypoxemia on the cardiovascular system?
- A. Heart block
- B. Restlessness
- C. Tachycardia
- D. Tachypnea
Correct Answer: C
Rationale: The correct answer is C: Tachycardia. Hypoxemia results in decreased oxygen levels in the blood, stimulating the body to increase heart rate to improve oxygen delivery. Tachycardia is an early sign of the cardiovascular system compensating for hypoxemia. Heart block (A) is a disruption in the electrical conduction within the heart and is not directly related to hypoxemia. Restlessness (B) is a non-specific sign and can be caused by various factors. Tachypnea (D) is an increased respiratory rate, which is a response to hypoxemia but not a direct effect on the cardiovascular system.
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When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse manager will plan to obtain adequate quantities of:
- A. Vaccine.
- B. Atropine.
- C. Antibiotics.
- D. Whole blood.
Correct Answer: A
Rationale: The correct answer is A: Vaccine. Smallpox is a contagious and potentially deadly disease caused by the variola virus. The smallpox vaccine is the most effective way to prevent and control the spread of smallpox. By obtaining adequate quantities of the smallpox vaccine, the ED nurse manager can protect healthcare workers and the public from contracting the virus in case of a smallpox bioterrorism event. Atropine (B) is used to treat certain types of nerve agent poisoning, not smallpox. Antibiotics (C) are ineffective against viruses like smallpox. Whole blood (D) is not specifically needed for smallpox treatment.
The nurse caring for a mechanically ventilated patient prepares to include which strategies to prevent ventilator-associated pneumonia should be into the patient’s plan of care? (Select all that apply.)
- A. Drain condensate from the ventilator tubing away from the patient.
- B. Elevate the head of the bed 30 to 45 degrees.
- C. Instill normal saline as part of the suctioning procedure.
- D. Perform regular oral care with chlorhexidine.
Correct Answer: A
Rationale: The correct answer is A: Drain condensate from the ventilator tubing away from the patient. This is crucial to prevent ventilator-associated pneumonia as stagnant condensate can harbor harmful bacteria. By draining it away from the patient, the risk of bacterial growth and subsequent aspiration is minimized. Elevating the head of the bed (choice B) helps prevent aspiration but is not specific to preventing ventilator-associated pneumonia. Instilling normal saline during suctioning (choice C) can increase the risk of infection. Performing regular oral care with chlorhexidine (choice D) is important for oral hygiene but not directly related to preventing ventilator-associated pneumonia.
Continuous venovenous hemodialysis is used to
- A. remove fluids and solutes through the process of convection.
- B. remove plasma water in cases of volume overload.
- C. remove plasma water and solutes by adding dialysate.
- D. combine ultrafiltration, convection and dialysis
Correct Answer: D
Rationale: The correct answer is D because continuous venovenous hemodialysis combines ultrafiltration, convection, and dialysis techniques. Ultrafiltration removes excess fluid, convection helps in removing solutes, and dialysis involves the diffusion of solutes across a semipermeable membrane. This comprehensive approach ensures effective removal of both fluid and solutes in critically ill patients.
Incorrect Answer Analysis:
A: Removing fluids and solutes through convection alone is not the complete process in continuous venovenous hemodialysis.
B: While volume overload is addressed, continuous venovenous hemodialysis involves more than just removing plasma water.
C: Adding dialysate is not the primary method in continuous venovenous hemodialysis; it involves ultrafiltration, convection, and dialysis techniques.
What nursing strategies help families cope with the stress of critical illness? (Select all that apply.)
- A. Asking the family to leave during the morning bath to promote the patient’s privacy.
- B. Encouraging family members to make notes of questio ns they have for the physician during family rounds.
- C. When possible, providing continuity of nursing care.
- D. Providing a daily update of the patient’s condition to the family spokesperson.
Correct Answer: B
Rationale: The correct answer is B: Encouraging family members to make notes of questions they have for the physician during family rounds. This strategy helps families cope with the stress of critical illness by empowering them to stay informed and actively participate in the patient's care. By encouraging them to make notes, it promotes effective communication with the healthcare team and ensures that their concerns and questions are addressed promptly.
Other choices are incorrect:
A: Asking the family to leave during the morning bath to promote the patient’s privacy is not a helpful strategy for coping with stress as it may lead to feelings of isolation and lack of involvement in the patient's care.
C: Providing continuity of nursing care is important but may not directly address the family's coping mechanisms during a critical illness.
D: Providing a daily update of the patient’s condition to the family spokesperson is valuable but may not fully address the family's need for active participation and communication with the healthcare team.
The emergency department (ED) nurse is initiating therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)?
- A. Continuously monitor heart rhythm.
- B. Check neurologic status every 2 hours.
- C. Place cooling blankets above and below the patient.
- D. Give acetaminophen (Tylenol) 650 mg per nasogastric tube.
Correct Answer: D
Rationale: Correct Answer: D - Give acetaminophen (Tylenol) 650 mg per nasogastric tube.
Rationale: LPNs/LVNs are trained to administer medications, including oral and nasogastric routes. Giving acetaminophen via nasogastric tube is within their scope of practice. LPNs/LVNs should have the knowledge and skills to safely administer this medication as part of the hypothermia protocol.
Summary of other choices:
A: Continuously monitor heart rhythm - This requires specialized training and skills typically within the scope of registered nurses or cardiac monitoring technicians.
B: Check neurologic status every 2 hours - Assessing neurologic status requires critical thinking and clinical judgment, which are typically responsibilities of registered nurses.
C: Place cooling blankets above and below the patient - Positioning and managing cooling devices may require specific training and should be done under the supervision of a registered nurse.