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After a change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first?
- A. Patient who failed a spontaneous breathing trial and has been placed in rest mode on the ventilator.
- B. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring.
- C. Patient with central venous oxygen saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP).
- D. Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours.
Correct Answer: D
Rationale: The correct answer is D - Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours. This patient should be assessed first because the absence of urine output for 6 hours after being extubated could indicate acute kidney injury or other serious complications that need immediate attention. Urine output is a crucial indicator of renal function and can reflect the patient's overall hemodynamic status. In contrast, the other choices do not present immediate life-threatening conditions. Choice A involves a patient in rest mode post-failed breathing trial, which does not require immediate assessment. Choice B mentions continuous PETCO2 monitoring, which is important but not as urgent as assessing a patient with no urine output. Choice C describes a patient with a ScvO2 of 69%, which may need monitoring but does not indicate an urgent priority compared to assessing a patient with no urine output after recent extubation.
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The nurse is assessing a patient with a new arteriovenous fistula, but does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable. The nurse should
- A. reassess the patient in an hour.
- B. raise the arm above the level of the patient’s heart.
- C. notify the provider immediately.
- D. apply warm packs to the fistula site and reassess.
Correct Answer: C
Rationale: The correct answer is C: notify the provider immediately. The absence of bruit, thrill, and palpable distal pulses in a new arteriovenous fistula suggests potential complications like thrombosis or stenosis, requiring urgent intervention. Notifying the provider promptly allows for timely assessment and appropriate management to prevent further complications.
Summary:
A: Reassessing the patient in an hour may delay necessary intervention for a potentially serious issue.
B: Raising the arm above the level of the patient’s heart does not address the underlying problem and may not improve the situation.
D: Applying warm packs to the fistula site is not the appropriate intervention for the absence of bruit and thrill and may not address the underlying cause.
The nurse calculates the PaO /FiO ratio for the following values: PaO is 78 mm Hg; FiO is 2 2 2 2 6 (60%). What is the outcome and the relationship to the ARDS diagnosing criteria?
- A. 46.8; meets criteria for ARDS
- B. 130; meets criteria for ARDS
- C. 468; normal lung function
- D. Not enough data to compute the ratio
Correct Answer: A
Rationale: The correct answer is A: 46.8; meets criteria for ARDS. The PaO /FiO ratio is calculated by dividing the arterial oxygen partial pressure (PaO) by the fraction of inspired oxygen (FiO). In this case, PaO is 78 mm Hg and FiO is 0.6 (60%). Therefore, the calculation would be 78/0.6 = 130. This value is less than 300, which is indicative of ARDS according to the Berlin criteria. Choices B and C are incorrect as they do not align with the criteria for ARDS. Choice D is incorrect because the data provided is sufficient to compute the ratio.
What is the focus of the synergy model of practice?
- A. Allowing unrestricted visiting for the patient 24 hours aebaircbh.c odma/tye.s t
- B. Providing holistic and alternative therapies.
- C. Considering the needs of patients and their families, w hich drives nursing competency.
- D. Addressing the patients’ needs for energy and support.
Correct Answer: C
Rationale: The correct answer is C because the synergy model of practice emphasizes considering the needs of patients and their families, which in turn drives nursing competency. This approach recognizes that patient care is not just about the individual but also about the broader support system. This holistic viewpoint helps nurses tailor their care to meet the unique needs of each patient and their family, ultimately leading to better outcomes.
Choices A, B, and D are incorrect:
A: Allowing unrestricted visiting for the patient 24 hours is not directly related to the focus of the synergy model which is more about patient-centered care.
B: Providing holistic and alternative therapies is a valid approach, but it is not the primary focus of the synergy model.
D: Addressing the patients' needs for energy and support is important but does not capture the comprehensive nature of the synergy model which encompasses the needs of both patients and their families.
A hospice patient with end-stage renal disease refuses to eat or drink and is very weak but reports no pain. Which nursing action is most appropriate?
- A. Teach the family about the use of enteral feedings to improve nutrition.
- B. Discuss the benefits of inserting a feeding tube for hydration.
- C. Provide support for the patient’s decision and ensure comfort measures.
- D. Inform the patient about the risks of refusing food and fluids.
Correct Answer: C
Rationale: The most appropriate nursing action in this scenario is choice C: Provide support for the patient’s decision and ensure comfort measures. This is because the patient is in hospice care, indicating a focus on comfort and quality of life rather than aggressive treatments. By respecting the patient’s decision and providing comfort measures, the nurse promotes dignity and autonomy. Choices A and B are not suitable as they go against the patient's wishes and may cause distress. Choice D, while important, is not the immediate priority when the patient is not in pain and has chosen to refuse food and fluids. Overall, choice C aligns with the principles of hospice care and prioritizes the patient's comfort and autonomy.
The critical care unit environment is very stressful for patients, families, and staff. What nursing action is directed at reducing environmental stress?
- A. Constant evaluation of patient status
- B. Limiting visits to immediate family
- C. Bathing all patients during hours of sleep
- D. Maintaining quiet during hours of sleep
Correct Answer: D
Rationale: The correct answer is D: Maintaining quiet during hours of sleep. This action is essential in reducing environmental stress in the critical care unit as it promotes a restful environment for patients and allows for better sleep quality. Noise can disrupt sleep patterns and increase stress levels. Constant evaluation of patient status (A) is important but does not directly address environmental stress. Limiting visits to immediate family (B) can be beneficial in some cases but may not always reduce environmental stress. Bathing all patients during hours of sleep (C) may actually increase stress as it can be disruptive and uncomfortable for patients. Overall, maintaining a quiet environment during sleep hours is the most effective nursing action to reduce environmental stress in the critical care unit.