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A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?
- A. Heart rate.
- B. Breath sounds.
- C. Body temperature.
- D. Level of consciousness.
Correct Answer: C
Rationale: The correct answer is C: Body temperature. In a patient who has fallen through the ice, hypothermia is a major concern due to exposure to cold water. Assessing body temperature first is crucial to determine the severity of hypothermia and guide immediate interventions. Heart rate, breath sounds, and level of consciousness can be affected by hypothermia but are secondary assessments. Assessing body temperature is the priority to address the most life-threatening issue first.
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In calculating the glomerular filtration rate (GFR) results for women, the creatinine clearance is usually:
- A. the same as for men.
- B. greater than that for men.
- C. multiplied by 0.85
- D. multiplied by 1.15.
Correct Answer: C
Rationale: The correct answer is C: multiplied by 0.85. This is because women typically have lower muscle mass compared to men, resulting in lower creatinine production. Therefore, to adjust for this difference, the creatinine clearance for women is multiplied by 0.85. This correction factor helps to more accurately estimate the GFR in women.
Choices A and B are incorrect because the creatinine clearance for women is not the same as or greater than that for men due to the physiological differences in muscle mass. Choice D is also incorrect as multiplying by 1.15 would overestimate the GFR in women.
The nurse assesses a patient who is admitted for an overdo se of sedatives. The nurse expects to find which acid-base alteration?
- A. Hyperventilation and respiratory acidosis
- B. Hypoventilation and respiratory acidosis
- C. Hypoventilation and respiratory alkalosis
- D. Respiratory acidosis and normal oxygen levels
Correct Answer: B
Rationale: The correct answer is B: Hypoventilation and respiratory acidosis. When a patient overdoses on sedatives, it can lead to respiratory depression causing hypoventilation. Hypoventilation results in retention of CO2, leading to respiratory acidosis. This is because the body is not effectively exhaling CO2, causing an increase in carbonic acid levels and a decrease in blood pH. The other choices are incorrect because hyperventilation would lead to respiratory alkalosis (Choice A), hypoventilation does not cause respiratory alkalosis (Choice C), and normal oxygen levels do not indicate the acid-base imbalance caused by sedative overdose (Choice D).
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.
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 nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the healthcare provider immediately if the patient develops:
- A. Oxygen saturation of 93%.
- B. Respirations of 20 breaths/minute.
- C. Green nasogastric tube drainage.
- D. Increased jugular venous distention.
Correct Answer: D
Rationale: The correct answer is D: Increased jugular venous distention. In a patient with a subarachnoid hemorrhage and on mechanical ventilation, increased jugular venous distention can indicate increased intracranial pressure, which can be life-threatening. The nurse should notify the healthcare provider immediately as it may require urgent intervention to prevent further neurological deterioration.
A: Oxygen saturation of 93% is within the acceptable range for a patient on mechanical ventilation and may not require immediate notification.
B: Respirations of 20 breaths/minute are within normal limits for a ventilated patient and do not necessarily indicate a critical condition.
C: Green nasogastric tube drainage may indicate the presence of bile and could be related to gastrointestinal issues, but it does not pose an immediate threat to the patient's neurological status.