Nokea
A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of:
- A. Peritoneal lavage.
- B. Abdominal ultrasonography.
- C. Nasogastric (NG) tube placement.
- D. Magnetic resonance imaging (MRI).
Correct Answer: B
Rationale: The correct answer is B: Abdominal ultrasonography. This is because ultrasonography is a non-invasive imaging technique that can quickly evaluate for internal injuries such as organ damage or bleeding in patients with blunt abdominal trauma. It is a rapid and effective diagnostic tool to assess the extent of injury and guide further management.
Peritoneal lavage (A) is an invasive procedure used in trauma settings to detect intra-abdominal bleeding but is not typically used for teaching purposes. Nasogastric tube placement (C) is used for decompression and drainage in certain conditions but is not relevant for assessing abdominal trauma. Magnetic resonance imaging (MRI) (D) is not typically used as the initial imaging modality for acute trauma due to time constraints and its limited availability in emergency settings.
You may also like to solve these questions
The nurse cites evidence-based practice as a rationale for a patient care decision. What isthe best description of evidence-based practice?
- A. Decisions based on expert legal testimony
- B. Use of best available research data
- C. Evolution of nursing practice over time
- D. Individual optimization of patient outcomes
Correct Answer: B
Rationale: The correct answer is B: Use of best available research data. Evidence-based practice involves integrating the best available research evidence with clinical expertise and patient values to make informed decisions about patient care. It emphasizes using scientifically proven data to guide practice and improve patient outcomes. Expert legal testimony (A) is not necessarily evidence-based. Evolution of nursing practice over time (C) does not specifically focus on research data. Individual optimization of patient outcomes (D) is a goal of evidence-based practice, but it does not fully encompass the concept.
The nurse cares for an adolescent patient who is dying. The patient’s parents are interested in organ donation and ask the nurse how the decision about brain death is made. Which response by the nurse is most appropriate?
- A. Brain death occurs if a person is flaccid and unresponsive.
- B. If CPR is ineffective in restoring a heartbeat, the brain cannot function.
- C. Brain death has occurred if there is no breathing and certain reflexes are absent.
- D. If respiratory efforts cease and no apical pulse is audible, brain death is present.
Correct Answer: C
Rationale: The correct answer is C: Brain death has occurred if there is no breathing and certain reflexes are absent. Brain death is defined as the irreversible cessation of all functions of the entire brain, including the brainstem. The absence of breathing and certain reflexes, such as no response to painful stimuli or no pupillary response to light, are key indicators of brain death. This definition is crucial for determining eligibility for organ donation.
Incorrect choices:
A: Brain death occurs if a person is flaccid and unresponsive. Flaccidity and unresponsiveness are not specific criteria for diagnosing brain death.
B: If CPR is ineffective in restoring a heartbeat, the brain cannot function. The absence of a heartbeat alone does not indicate brain death.
D: If respiratory efforts cease and no apical pulse is audible, brain death is present. Respiratory cessation and the absence of pulse are not definitive signs of brain death.
A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement?
- A. Fit the client with a respirator mask.
- B. Assign the client to a negative air-flow room.
- C. Don a clean gown for client care.
- D. Place an isolation cart in the hallway.
Correct Answer: B
Rationale: The correct answer is B: Assign the client to a negative air-flow room. This is crucial to prevent the spread of TB to other patients and healthcare workers. Negative air-flow rooms help contain airborne pathogens. Option A is not sufficient as it only protects the client, not others. Option C is important for infection control but not the priority in this situation. Option D is not as effective as placing the client in a negative air-flow room. Overall, option B is the best choice to ensure the safety of everyone in the unit.
The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces th e risk of catheter-related bloodstream infection (CRBSI)?
- A. Review daily the necessity of the central venous cathet er.
- B. Cleanse the insertion site daily with isopropyl alcohol.
- C. Change the pressurized tubing system and flush bag daily.
- D. Maintain a pressure of 300 mm Hg on the flush bag.
Correct Answer: A
Rationale: The correct answer is A: Review daily the necessity of the central venous catheter. This action reduces the risk of CRBSI by promoting early removal of unnecessary catheters, which is a key strategy in preventing infections. Unnecessary catheters increase the risk of infection due to prolonged exposure to the patient's skin flora and possible contamination during insertion. Reviewing daily ensures the catheter is only kept when necessary, minimizing the duration of catheter use and reducing the chances of infection.
Summary of other choices:
B: Cleansing the insertion site daily with isopropyl alcohol is important for maintaining skin integrity but does not directly reduce the risk of CRBSI.
C: Changing the pressurized tubing system and flush bag daily is important for maintaining catheter patency but does not directly reduce the risk of CRBSI.
D: Maintaining a pressure of 300 mm Hg on the flush bag is important for proper catheter function but does not directly reduce the risk of CR
The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, hear t rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value reqaubiirrbe.sco imm/temste diate action by the nurse?
- A. Cardiac index (CI) of 1.2 L/min/m3
- B. Cardiac output (CO) of 4 L/min
- C. Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm5
- D. Systemic vascular resistance (SVR) of 1800 dynes/sec /cm5
Correct Answer: B
Rationale: The correct answer is B: Cardiac output (CO) of 4 L/min. In this scenario, the patient is presenting with signs of pulmonary congestion and hypoxemia, indicating possible cardiogenic pulmonary edema. As the cardiac output is a key indicator of how well the heart is functioning and delivering blood to the body, a low cardiac output can lead to inadequate tissue perfusion and worsen the patient's condition. Therefore, immediate action is required to address the low cardiac output to improve tissue perfusion and oxygenation.
Choices A, C, and D are incorrect as they do not directly address the primary concern of inadequate cardiac output in this patient. Cardiac index, pulmonary vascular resistance, and systemic vascular resistance are important parameters to monitor, but in this case, the priority is to address the low cardiac output to improve the patient's condition.