Nokea
A patient in the ICU develops acute respiratory distress syndrome (ARDS) with severe hypoxemia refractory to conventional oxygen therapy. What intervention should the healthcare team prioritize to improve the patient's oxygenation?
- A. Initiate prone positioning to optimize lung recruitment.
- B. Administer inhaled pulmonary vasodilators for vasodilation.
- C. Perform recruitment maneuvers to open collapsed alveoli.
- D. Recommend extracorporeal membrane oxygenation (ECMO) for respiratory support.
Correct Answer: D
Rationale: In the scenario described, the patient is experiencing severe hypoxemia refractory to conventional oxygen therapy, indicating a need for advanced respiratory support. When a patient with ARDS fails to respond to conservative management, including mechanical ventilation strategies, prone positioning, and recruitment maneuvers, the next step may involve extracorporeal membrane oxygenation (ECMO). ECMO provides a way to bypass the lungs and oxygenate the blood directly, allowing for enhanced gas exchange and support for severely compromised respiratory function. Therefore, in this critical situation, prioritizing the recommendation for ECMO can offer the patient the best chance of improving oxygenation and survival.
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A postpartum client who delivered a preterm infant expresses concerns about milk supply and worries about meeting the baby's nutritional needs. What nursing intervention should be prioritized to address the client's concerns?
- A. Providing education on techniques to enhance milk production and supply
- B. Recommending supplemental formula feedings to ensure adequate nutrition
- C. Encouraging the client to avoid breastfeeding until the infant reaches full term
- D. Referring the client to a dietitian for specialized nutritional support
Correct Answer: A
Rationale: Providing education on techniques to enhance milk production and supply should be prioritized to address the client's concerns about milk supply and meeting the baby's nutritional needs. By educating the client on proper breastfeeding techniques, frequent nursing sessions, skin-to-skin contact, and the importance of staying hydrated, the nurse can help promote successful breastfeeding and potentially increase milk production. Supplemental formula feedings are not the first line of intervention, as breastfeeding should be encouraged, especially for a preterm infant who may benefit significantly from breast milk. Encouraging the client to avoid breastfeeding until the infant reaches full term is not appropriate, as breastfeeding can still be beneficial for a preterm infant. Referring the client to a dietitian for specialized nutritional support may be beneficial, but addressing milk supply concerns through education should be prioritized initially to support breastfeeding success.
What nursing diagnosis would be MOST appropriate for a client admitted with heart failure?
- A. Risk for denial
- B. Ineffective tissue perfusion
- C. Impaired gas exchange
- D. Acute pain
Correct Answer: B
Rationale: Heart failure is a condition in which the heart is unable to pump enough blood to meet the body's need for oxygen and nutrients. Ineffective tissue perfusion is a relevant nursing diagnosis for a client with heart failure because the heart's inability to effectively pump blood can lead to poor perfusion of tissues and organs, resulting in inadequate oxygen and nutrient delivery to cells. This can lead to symptoms such as fatigue, dyspnea, and edema, which are common in individuals with heart failure. By addressing ineffective tissue perfusion, nurses can focus on interventions to improve cardiac output and optimize tissue perfusion, ultimately improving the client's overall condition.
If Baby Sharon develops dehydration, what is the FIRST sign to look for by Nurse Juvy?
- A. Oliguria
- B. Sunken fontanels
- C. Soft and depressed eyeballs
- D. Non-elastic skin/poor skin turgor on thighs and abdomen Situation 3 -
Correct Answer: B
Rationale: Sunken fontanels are one of the earliest signs of dehydration in infants. Fontanels are soft spots on an infant's head where the skull bones have not yet fused together. If a baby's fontanel appears sunken, it indicates that the baby is likely dehydrated. This occurs because when there is a lack of fluid in the body, the soft spots on the head will appear depressed or sunken. It is crucial for Nurse Juvy to closely monitor the fontanels of Baby Sharon, as identifying dehydration early is essential for prompt intervention and preventing complications.
During surgery, the nurse notices an abnormal heart rhythm on the patient's cardiac monitor. What is the nurse's priority action?
- A. Administer antiarrhythmic medication
- B. Assess the patient's vital signs and symptoms
- C. Document the rhythm in the patient's chart
- D. Inform the anesthesiologist immediately
Correct Answer: B
Rationale: The nurse's priority action when noticing an abnormal heart rhythm on the patient's cardiac monitor during surgery is to assess the patient's vital signs and symptoms. This is important because the nurse needs to gather more information about the patient's condition to determine the significance of the abnormal rhythm and the potential impact on the patient's health. By assessing the vital signs and symptoms, the nurse can obtain a more complete picture of the situation and make informed decisions about the next steps in caring for the patient. Once the assessment is done, appropriate actions such as administering medication or notifying the anesthesiologist can be taken based on the findings.
Patient Benito ask5 Nurse Virgo, "Why can't the surgeon just take out my pancreas?" The BEST response of Nurse Virgo is
- A. "your body needs to function well with your pancreas "
- B. "your attack will soon be overcome when you are at rest"
- C. "if your pancreas is removed, you can never eat fat and fried foods again"
- D. "antibiotic wil1 relieve signs of infection"
Correct Answer: A
Rationale: The best response of Nurse Virgo is to explain to Patient Benito that his body needs to function well with his pancreas. The pancreas plays a critical role in the digestive system by producing digestive enzymes and hormones that help regulate blood sugar levels. Removing the pancreas would result in serious health consequences and complications, as the body relies on it for essential functions. It is important for the patient to understand the significance of the pancreas and why its removal is not a viable solution.