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A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement?
- A. Fit the client with a respirator mask.
- B. Assign the client to a negative air-flow room.
- C. Don a clean gown for client care.
- D. Place an isolation cart in the hallway.
Correct Answer: B
Rationale: The correct answer is B: Assign the client to a negative air-flow room. This is crucial to prevent the spread of TB to other patients and healthcare workers. Negative air-flow rooms help contain airborne pathogens. Option A is not sufficient as it only protects the client, not others. Option C is important for infection control but not the priority in this situation. Option D is not as effective as placing the client in a negative air-flow room. Overall, option B is the best choice to ensure the safety of everyone in the unit.
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Which interventions may be included during “terminal we aning”? (Select all that apply.)
- A. Complete extubation following ventilator withdrawal
- B. Discontinuation of artificial ventilation but maintenanc e of the artificial airway
- C. Discontinuation of anxiolytic and pain medications
- D. Titration of ventilator support based upon blood gas de terminations
Correct Answer: B
Rationale: The correct answer is B because during terminal weaning, the artificial ventilation is discontinued while maintaining the artificial airway to ensure comfort and support. This allows the patient to breathe on their own with support as needed.
Explanation:
1. Option A: Complete extubation following ventilator withdrawal may not be suitable during terminal weaning as it involves removing the breathing tube entirely.
2. Option C: Discontinuation of anxiolytic and pain medications may not always be appropriate during terminal weaning as it depends on the patient's comfort needs.
3. Option D: Titration of ventilator support based on blood gas determinations is not typically done during terminal weaning as the focus is on gradual withdrawal of ventilation support while maintaining comfort.
The nurse is preparing to measure the thermodilution cardaiabicrb o.cuomtp/tuest t (TdCO) in a patient being monitored with a pulmonary artery catheter. Which action by the nurse best ensures the safety of the patient?
- A. Ensure the transducer system is zero referenced at the level of the phlebostatic axis.
- B. Avoid infusing vasoactive agents in the port used to ob tain the TdCO measurement.
- C. Maintain a pressure of 300 mm Hg on the flush solutioanbi rub.scionmg/t eas tp ressure bag.
- D. Limit the length of the noncompliant pressure tubing to a maximum 48 inches.
Correct Answer: B
Rationale: The correct answer is B: Avoid infusing vasoactive agents in the port used to obtain the TdCO measurement. This action ensures patient safety by preventing the introduction of vasoactive agents directly into the bloodstream during the measurement process. Infusing vasoactive agents can lead to inaccurate TdCO readings and potentially harm the patient.
Choice A is incorrect because zero referencing the transducer system at the level of the phlebostatic axis is important for accurate pressure monitoring but not directly related to TdCO measurement safety.
Choice C is incorrect as maintaining a pressure of 300 mm Hg on the flush solution bag is not directly related to the safety of TdCO measurement.
Choice D is incorrect as limiting the length of noncompliant pressure tubing is important for accurate pressure readings but not directly related to the safety of TdCO measurement.
The nurse is caring for a critically ill trauma patient who is expected to be hospitalized for an extended period of time. Which of the following nursing interventions would improve the patient’s well-being and reduce anxiety the most?
- A. Arrange for the patient’s dog to be brought into the unit (per protocol).
- B. Contact the pet therapy department to bring a therapy d og in to visit.
- C. Secure the harpist to come and play soothing music fora bairnb. choomu/tre set very afternoon.
- D. Wheel the patient out near the unit aquarium to observ e the tropical fish.
Correct Answer: B
Rationale: The correct answer is B because pet therapy has been shown to reduce anxiety and improve well-being in hospitalized patients. Interacting with therapy dogs can provide comfort, companionship, and a distraction from the hospital environment. Bringing in a therapy dog can help the trauma patient feel more relaxed and supported during their extended hospital stay.
Choice A may be comforting but does not address the therapeutic benefits of pet therapy. Choice C may provide soothing music, but pet therapy has been specifically proven to reduce anxiety in patients. Choice D, observing fish in an aquarium, may be calming but does not involve the interactive benefits of pet therapy.
A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is 'his' and he doesn’t want any more contact with the hospital. How should the nurse respond?
- A. This hospital does not need to keep it if you are leaving and not returning here.
- B. Because you are leaving against medical advice, you may not have your chart.
- C. The information in your chart is confidential and cannot leave this facility legally.
- D. The chart is the property of the hospital but I will see that a copy is made for you.
Correct Answer: D
Rationale: The correct answer is D because the client's medical chart is the property of the hospital, but the client has the right to a copy of the information. By offering to make a copy of the chart for the client, the nurse respects the client's autonomy while also ensuring that the hospital maintains the original medical record. This response balances the client's rights with legal and ethical considerations.
Choice A is incorrect because the hospital is legally obligated to maintain the client's medical record even if the client leaves against medical advice. Choice B is incorrect as it denies the client access to their medical information, which goes against the principle of patient autonomy. Choice C is also incorrect as it does not address the client's request for a copy of their chart.
Renin plays a role in blood pressure regulation by
- A. activating the renin-angiotensin-aldosterone cascade.
- B. suppressing angiotensin production.
- C. decreasing sodium reabsorption.
- D. inhibiting aldosterone release.
Correct Answer: A
Rationale: The correct answer is A because renin activates the renin-angiotensin-aldosterone cascade, which ultimately leads to vasoconstriction, increased blood pressure, and aldosterone release to increase sodium and water reabsorption. Renin does not suppress angiotensin production (B), decrease sodium reabsorption (C), or inhibit aldosterone release (D), as these actions would counteract its role in blood pressure regulation.