Nokea
A hospice patient is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. Which statement, if made by the nurse to the patient’s family member, is most appropriate?
- A. These symptoms will continue to increase until death finally occurs.
- B. These symptoms are a normal response before these functions decrease.
- C. These symptoms indicate a reflex response to the slowing of other body systems.
- D. These symptoms may be associated with an improvement in the patient’s condition.
Correct Answer: B
Rationale: The correct answer is B because an increase in heart rate and respiratory rate can be a normal response before body system functions decrease in a hospice patient. This is known as a compensatory mechanism as the body tries to maintain oxygenation. Choice A is incorrect because symptoms may not always continue to increase until death. Choice C is incorrect as it implies a reflex response, which may not be the case. Choice D is incorrect as an improvement in the patient's condition is unlikely in a hospice setting.
You may also like to solve these questions
Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action?
- A. The right hand is cooler than the left.
- B. The mean arterial pressure (MAP) is 77 mm Hg.
- C. The system is delivering 3 mL of flush solution per hour.
- D. The flush bag and tubing were last changed 3 days previously.
Correct Answer: A
Rationale: The correct answer is A because a cooler right hand may indicate compromised circulation, potentially due to arterial occlusion or clot formation. This could lead to inadequate perfusion and tissue damage. Immediate action is needed to assess and address the cause.
Choice B is incorrect because a MAP of 77 mm Hg is within the normal range for most patients and does not require immediate action.
Choice C is incorrect as delivering 3 mL of flush solution per hour is an appropriate rate and does not indicate a need for immediate action.
Choice D is incorrect as the flush bag and tubing being changed 3 days ago does not necessarily indicate an immediate issue with the arterial line function.
The patient undergoes a cardiac catheterization that requires the use of contrast dyes during the procedure. To detect signs of contrast-induced kidney injury, the nurse should
- A. not be concerned unless urine output decreases.
- B. evaluate the patient’s serum creatinine for up to 72 hours after the procedure.
- C. obtain an order for a renal ultrasound.
- D. evaluate the patient’s postvoid residual volume to detect intrarenal injury.
Correct Answer: B
Rationale: The correct answer is B because evaluating the patient's serum creatinine for up to 72 hours after the procedure is crucial in detecting contrast-induced kidney injury. An increase in serum creatinine levels indicates impaired kidney function due to the contrast dye. This monitoring allows for early detection and intervention to prevent further kidney damage.
Choice A is incorrect because a decrease in urine output is a late sign of kidney injury and may not be present in the early stages. Choice C is incorrect as a renal ultrasound is not typically used to detect contrast-induced kidney injury. Choice D is incorrect as postvoid residual volume assessment is not specific to detecting intrarenal injury related to contrast dye use.
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.
A patient’s ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from.60 to.70, and the positive end-expiratory pressure is increased from 10 to 15 cm H O. Shortly after these adjustments, the nurse notes that the patient’s blood pressure drops from 120/76 mm Hg to 90/60 mm Hg. What is the m ost likely cause of this decrease in blood pressure?
- A. Decrease in cardiac output
- B. Hypovolemia
- C. Increase in venous return
- D. Oxygen toxicity
Correct Answer: B
Rationale: The correct answer is B: Hypovolemia. When the ventilator settings are adjusted to treat hypoxemia by increasing FiO2 and PEEP, it can lead to increased oxygenation but also potentially decrease venous return to the heart, causing a decrease in blood pressure. This decrease in blood pressure is most likely due to hypovolemia, as the increased PEEP can increase intrathoracic pressure, reducing venous return and preload, leading to a decrease in cardiac output and subsequent decrease in blood pressure. This choice is the most likely cause as the other options (A: Decrease in cardiac output, C: Increase in venous return, D: Oxygen toxicity) do not directly correlate with the changes in ventilator settings described in the question.
The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly complains of abdominal pain and chills. The patient’s temperature is elevated. The nurse should
- A. assess peritoneal dialysate return.
- B. check the patient’s blood sugar.
- C. evaluate the patient’s neurological status.
- D. inform the provider of probable visceral perforation.
Correct Answer: D
Rationale: Step 1: Abdominal pain, chills, and elevated temperature suggest a serious complication like visceral perforation.
Step 2: Peritoneal dialysate return assessment won't address the potential life-threatening issue.
Step 3: Checking blood sugar or evaluating neurological status is not relevant to the presenting symptoms.
Step 4: Informing the provider of probable visceral perforation is crucial for prompt intervention and further evaluation.