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A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse implement next?
- A. Measure the blood pressure.
- B. Reassess the apical pulse.
- C. Notify the healthcare provider.
- D. Administer the medication.
Correct Answer: D
Rationale: The correct answer is D: Administer the medication. Atenolol is a beta-blocker used to reduce heart rate and blood pressure. In this scenario, the client's apical pulse of 65 beats per minute is within the normal range for a client taking atenolol after a myocardial infarction. Therefore, the nurse should proceed with administering the medication as prescribed to help maintain the client's heart rate and blood pressure within the therapeutic range.
A: Measuring the blood pressure is important but not the immediate next step as the client's heart rate is within the normal range.
B: Reassessing the apical pulse is unnecessary since it is already within the normal range for a client on atenolol.
C: Notifying the healthcare provider is not indicated as there are no signs of concern with the client's heart rate at 65 bpm.
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A patient who has been declared brain dead is considered a potential organ donor. In order to proceed with donation, the nurse must understand that applicable concept?
- A. A signed donor card mandates that organs be retrieved in the event of brain death.
- B. After brain death has been determined, perfusion and o xygenation of organs is maintained until organs can be removed in the operatin ag bi rbro .co omm /t. e st
- C. The healthcare proxy does not need to give consent for the retrieval of organs.
- D. Once a patient has been established as brain dead, life support is withdrawn and organs are retrieved.
Correct Answer: B
Rationale: The correct answer is B because after brain death is confirmed, maintaining perfusion and oxygenation of organs is crucial to ensure their viability for donation. This process allows organs to be retrieved in optimal condition during the operation. Choice A is incorrect because a signed donor card is not a legal mandate for organ retrieval. Choice C is incorrect as the healthcare proxy's consent is typically required for organ donation. Choice D is incorrect because life support is not immediately withdrawn upon brain death confirmation; instead, organ preservation measures are initiated.
The critical care environment is often stressful to a criticalalbyir bil.clo pma/tteiset nt. Identify stressors that are commonly stressful for the critically ill patient. (Select all that apply.)
- A. Alarms that sound from various devices
- B. Bright, fluorescent lighting
- C. Lack of day-night cues
- D. Sounds from the mechanical ventilator
Correct Answer: A
Rationale: The correct answer is A: Alarms that sound from various devices. In the critical care environment, alarms often indicate changes in the patient's condition, causing stress. Bright fluorescent lighting (B) may be bothersome but not directly related to patient stress. Lack of day-night cues (C) may disrupt sleep patterns but is not a direct stressor. Sounds from the mechanical ventilator (D) are essential for patient care and not inherently stressful.
The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?
- A. Tracheostomy tube suctioning.
- B. Medication administration.
- C. Colostomy care instruction.
- D. Client personal hygiene.
Correct Answer: B
Rationale: The correct answer is B: Medication administration. This is the priority because medication administration is time-sensitive and crucial for patient safety. It requires precise timing and cannot be delayed. Tracheostomy tube suctioning (A), colostomy care instruction (C), and client personal hygiene (D) are important nursing activities but can be adjusted within the schedule based on patient needs and acuity levels. Prioritizing medication administration ensures that patients receive their medications on time, preventing adverse events and promoting optimal health outcomes.
An elderly patient is admitted to the ICU with stage IV lung cancer, diabetes mellitus, and congestive heart failure. The health care team assembled to care for her is large and diverse, including an oncologist, a pulmonologist, an endocrinologist, a cardiologist, and others. The patient is not expected to survive more than a few weeks, and her husband is overwhelmed with stress and grief. Which nurse competency or competencies are most needed in this situation? Select all that apply.
- A. Clinical judgment
- B. Caring practices
- C. Collaboration
- D. Response to diversity
Correct Answer: B
Rationale: The correct answer is B: Caring practices. In this situation, the patient and her husband are dealing with complex medical conditions and emotional distress. Caring practices involve providing compassionate, empathetic, and supportive care to the patient and her family members during this difficult time. The nurse needs to show sensitivity, understanding, and emotional support to help them cope with their situation. Clinical judgment (A) is important but not the primary focus in this scenario. Collaboration (C) is essential in the interdisciplinary team, but caring practices take precedence in addressing the emotional needs. Response to diversity (D) is also important, but in this case, the focus is more on providing compassionate care rather than addressing cultural or social diversity issues.
What is the most common cause of a pulmonary embolus?
- A. An amniotic fluid embolus.
- B. A deep vein thrombosis from lower extremities.
- C. A fat embolus from a long bone fracture.
- D. Vegetation that dislodges from an infected central venous catheter.
Correct Answer: B
Rationale: The correct answer is B: A deep vein thrombosis from lower extremities. Deep vein thrombosis (DVT) is the most common cause of a pulmonary embolus as a blood clot can dislodge from the veins, travel to the lungs, and block blood flow. An amniotic fluid embolus (Choice A) occurs during childbirth and is rare as a cause of pulmonary embolism. A fat embolus (Choice C) typically occurs after a long bone fracture and is more likely to cause issues in the lungs. Vegetation from an infected central venous catheter (Choice D) can cause septic pulmonary embolism, but it is not as common as DVT.