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A patient is having difficulty weaning from mechanical ve ntilation. The nurse assesses the patient and notes what potential cause of this difficult weaning?
- A. Cardiac output of 6 L/min
- B. Hemoglobin of 8 g/dL
- C. Negative sputum culture and sensitivity
- D. White blood cell count of 8000
Correct Answer: B
Rationale: The correct answer is B: Hemoglobin of 8 g/dL. Low hemoglobin levels can lead to inadequate oxygen delivery to tissues, causing respiratory distress and difficulty weaning from mechanical ventilation. This is due to reduced oxygen-carrying capacity leading to increased work of breathing.
A: Cardiac output of 6 L/min is within normal range and not directly related to difficulty weaning from mechanical ventilation.
C: Negative sputum culture and sensitivity indicate absence of respiratory infection but not a direct cause of difficulty weaning.
D: White blood cell count of 8000 is within normal range and not a direct cause of difficulty weaning.
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The spouse of a patient with terminal cancer visits daily and cheerfully talks with the patient about wedding anniversary plans for the next year. When the nurse asks about any concerns, the spouse says, 'I’m busy at work, but otherwise, things are fine.' Which nursing diagnosis is most appropriate?
- A. Ineffective coping related to lack of grieving.
- B. Anxiety related to the complicated grieving process.
- C. Caregiver role strain related to feeling overwhelmed.
- D. Hopelessness related to knowledge deficit about cancer.
Correct Answer: A
Rationale: The correct answer is A: Ineffective coping related to lack of grieving. The spouse's behavior of avoiding the reality of the terminal illness and focusing on future plans indicates maladaptive coping. The cheerfulness and denial suggest a lack of acceptance and processing of the impending loss. This can lead to emotional distress and hinder the grieving process.
Choice B (Anxiety related to the complicated grieving process) is incorrect because the spouse's behavior does not exhibit signs of anxiety but rather avoidance and denial. Choice C (Caregiver role strain related to feeling overwhelmed) is incorrect as the spouse does not express feeling overwhelmed but instead deflects by focusing on work. Choice D (Hopelessness related to knowledge deficit about cancer) is incorrect because the spouse's behavior does not indicate hopelessness or lack of understanding about cancer, but rather an avoidance of facing the reality of the situation.
The nurse is caring for a mechanically ventilated patient an d is charting outside the patient’s room when the ventilator alarm sounds. What is the priorit y order for the nurse to complete these actions? (Put a comma and space between each answer choice.)
- A. Check quickly for possible causes of the alarm that can be fixed.
- B. After troubleshooting, connect back to mechanical venti lator and reassess patient.
- C. Go to patient’s bedside.
- D. Manually ventilate the patient while getting respiratory therapist.
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Going to the patient’s bedside is the priority as it allows the nurse to assess the patient's condition directly.
2. By being at the bedside, the nurse can quickly evaluate the patient's breathing, vital signs, and other indicators for immediate action.
3. Direct assessment enables timely intervention and avoids delays in addressing potential life-threatening situations.
4. Checking for possible causes of the alarm and reconnection to the ventilator can follow, but assessing the patient's immediate needs takes precedence.
In summary, choice C is correct because direct patient assessment is the fundamental step in responding to a ventilator alarm to ensure patient safety and timely intervention. Choices A, B, and D are incorrect as they focus on troubleshooting and technical aspects before directly assessing the patient's condition.
Which statement about family assessment is false?
- A. Assessment of structure (who comprises the family) is the last step in assessment.
- B. Interaction among family members is assessed.
- C. It is important to assess communication among family members to understand roles.
- D. Ongoing assessment is important, because family funcatbioirbn.cinomg/ tmesat y change during the course of illness.
Correct Answer: A
Rationale: The correct answer is A because assessing the structure of the family (who comprises the family) is not the last step in family assessment. The rationale is that understanding the family structure is essential at the beginning of the assessment process to identify key relationships and support systems. Assessing interaction among family members helps to understand dynamics and relationships within the family. Assessing communication is crucial to identify roles and patterns of interaction. Ongoing assessment is necessary as family dynamics can evolve throughout the illness. Therefore, A is false as family structure assessment is an important initial step, not the last step.
The amount of effort needed to maintain a given level of ventilation is referred to using what term?
- A. Compliance
- B. Resistance
- C. Tidal volume
- D. Work of breathing
Correct Answer: D
Rationale: The correct answer is D: Work of breathing. Work of breathing refers to the amount of effort required to maintain a specific level of ventilation. This includes the energy needed for inhalation and exhalation. Compliance (A) refers to the ease with which the lungs expand, resistance (B) is the opposition to airflow in the airways, and tidal volume (C) is the amount of air moved in and out of the lungs during normal breathing. Work of breathing encompasses the overall energy expenditure involved in the breathing process, making it the most appropriate term in this context.
A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action should the nurse include in the plan of care?
- A. Administer prescribed sedatives or opioids at bedtime to promote sleep.
- B. Cluster nursing activities so that the patient has uninterrupted rest periods.
- C. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps.
- D. Eliminate assessments between 0100 and 0600 to allow uninterrupted sleep.
Correct Answer: B
Rationale: The correct answer is B: Cluster nursing activities so that the patient has uninterrupted rest periods.
Rationale:
1. Clustering nursing activities allows for uninterrupted rest periods, essential for improving sleep quality and addressing disturbed sensory perception.
2. Administering sedatives or opioids (Option A) can lead to drug dependence, tolerance, and adverse effects in older adults.
3. Silencing alarms (Option C) compromises patient safety by impeding timely monitoring and response to critical events.
4. Eliminating assessments (Option D) between 0100 and 0600 disregards the necessity of monitoring vital signs and assessing patient condition around the clock.