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A patient presents to the emergency department in acute re spiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation?
- A. Emergency tracheostomy and mechanical ventilation
- B. Mechanical ventilation via an endotracheal tube
- C. Noninvasive positive-pressure ventilation (NPPV)
- D. Oxygen at 100% via bag-valve-mask device
Correct Answer: B
Rationale: The correct answer is B: Mechanical ventilation via an endotracheal tube. In acute respiratory failure, especially in the setting of pneumonia and COPD, mechanical ventilation is often necessary to support breathing. Endotracheal intubation allows for precise control of airway patency, oxygenation, and ventilation. Emergency tracheostomy (choice A) is typically reserved for long-term ventilatory support. Noninvasive positive-pressure ventilation (choice C) may not provide sufficient support in severe cases. Oxygen via bag-valve-mask (choice D) may not be adequate for ventilatory support in acute respiratory failure.
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The nurse is assessing pain levels in a critically ill patient . The nurse recognizes that which patient action as indicatin g the greatest level of pain?
- A. Brow lowering
- B. Eyelid closing
- C. Grimacing
- D. Staring
Correct Answer: C
Rationale: Correct Answer: C (Grimacing)
Rationale:
1. Grimacing is a universal nonverbal sign of pain.
2. It involves facial muscles, indicating a high level of discomfort.
3. Brow lowering and eyelid closing are subtle signs, less indicative of severe pain.
4. Staring may signify concentration, not necessarily pain.
Summary:
Grimacing is the correct choice as it directly correlates with pain intensity, unlike the other options which are less specific or relevant indicators of severe pain.
The most common reasons for initiating dialysis in acute kidney injury include which of the following? (Select all that apply.)
- A. Acidosis
- B. Hypokalemia
- C. Volume overload
- D. Hyperkalemia
Correct Answer: C
Rationale: The correct answer is C: Volume overload. In acute kidney injury, impaired kidney function leads to fluid retention, causing volume overload. Dialysis helps remove excess fluid to restore fluid balance. Acidosis and hyperkalemia are potential complications of acute kidney injury but not the primary reasons for initiating dialysis. Hypokalemia is unlikely in acute kidney injury due to impaired excretion of potassium by the kidneys. Therefore, the most common reason for initiating dialysis in acute kidney injury is to manage volume overload.
The vision of the American Association of Critical-Care N urses is a healthcare system driven by achieving what goal?
- A. Maintaining a healthy work environment.
- B. Providing care from a multiprofessional team under th e direction of a critical care physician.
- C. Effectively meeting the needs of critically ill patients a nd families.
- D. Creating respectful, healing, and humane environments.
Correct Answer: D
Rationale: The correct answer is D because the vision of the American Association of Critical-Care Nurses focuses on creating respectful, healing, and humane environments. This aligns with the core values of nursing, emphasizing compassion, dignity, and patient-centered care. A is incorrect as the focus is not solely on the work environment. B is incorrect as it emphasizes the role of physicians over the collaborative approach advocated by the AACN. C is incorrect as it only addresses meeting patient needs, whereas the vision encompasses a broader scope of creating healing environments.
A patient nearing death experiences increased secretions and noisy breathing. What is the nurse’s priority intervention?
- A. Provide suctioning every hour.
- B. Administer anticholinergic medications as prescribed.
- C. Elevate the head of the bed and reposition frequently.
- D. Restrict oral intake to minimize secretions.
Correct Answer: B
Rationale: The correct answer is B: Administer anticholinergic medications as prescribed. Anticholinergic medications can help dry up secretions and improve breathing in a patient nearing death. This intervention targets the underlying cause of increased secretions. Suctioning (choice A) may provide temporary relief but does not address the root issue. Elevating the head of the bed and repositioning (choice C) can help with comfort but do not directly address the secretions. Restricting oral intake (choice D) may lead to dehydration and discomfort without effectively managing the secretions. Administering anticholinergic medications is the priority as it directly targets the symptom of increased secretions, improving the patient's comfort and quality of life.
The nurse cares for a patient with lung cancer in a home hospice program. Which action by the nurse is most appropriate?
- A. Discuss cancer risk factors and appropriate lifestyle modifications.
- B. Encourage the patient to discuss past life events and their meaning.
- C. Teach the patient about the purpose of chemotherapy and radiation.
- D. Accomplish a thorough head-to-toe assessment several times a week.
Correct Answer: B
Rationale: The correct answer is B because in a home hospice program, it is essential for the nurse to provide holistic care that includes addressing the patient's emotional and psychological needs. Encouraging the patient to discuss past life events and their meaning can help them process emotions, find closure, and improve their quality of life. This approach aligns with the principles of palliative care, which focus on enhancing comfort and well-being.
Choice A is incorrect because discussing cancer risk factors and lifestyle modifications may not be relevant or beneficial for a patient in a hospice program. Choice C is incorrect because chemotherapy and radiation are typically not part of hospice care, which focuses on comfort rather than curative treatments. Choice D is incorrect because a thorough head-to-toe assessment multiple times a week may not be necessary or appropriate for a patient in a hospice program.