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After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care?
- A. Apply external cooling device.
- B. Check mental status every 15 minutes.
- C. Avoid the use of sedative medications.
- D. Rewarm if the temperature is <91°F (32.8°C).
Correct Answer: A
Rationale: The correct answer is A: Apply external cooling device. Therapeutic hypothermia is a treatment used to protect the brain after cardiac arrest by lowering the body temperature. The nurse should use external cooling devices, such as cooling blankets or ice packs, to achieve and maintain the desired temperature. This method allows for precise temperature control and monitoring. Checking mental status every 15 minutes (choice B) is not the priority as maintaining the temperature is crucial. Avoiding sedative medications (choice C) may be necessary to accurately assess the patient's neurological status. Rewarming if the temperature is <91°F (32.8°C) (choice D) is incorrect as the goal is to maintain hypothermia for a specific duration before gradual rewarming.
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The patient is in the critical care unit and will receive dialysis this morning. The nurse will (Select all that apply.)
- A. evaluate morning laboratory results and report abnormal results.
- B. administer the patient’s antihypertensive medications.
- C. assess the dialysis access site and report abnormalities.
- D. weigh the patient to monitor fluid status.
Correct Answer: A
Rationale: The correct answer is A because evaluating morning lab results is crucial to monitor the patient's condition before dialysis. Abnormal results may impact the dialysis treatment plan. Option B is incorrect as administering antihypertensive medications is not directly related to dialysis. Option C is incorrect as assessing the dialysis access site is the responsibility of the dialysis team. Option D is incorrect as weighing the patient is not typically done immediately before dialysis.
Which of the following statements describes the core conc ept of the synergy model of practice?
- A. All nurses must be certified in order to have the synerg y model implemented.
- B. Family members must be included in daily interdisciplaibnirabr.cyo mro/teusnt ds.
- C. Nurses and physicians must work collaboratively and synergistically to influence care.
- D. Unique needs of patients and their families influence nursing competencies.
Correct Answer: D
Rationale: Rationale:
D is correct because the synergy model focuses on individualized care based on patients' unique needs. This model emphasizes tailoring nursing competencies to address these needs, promoting holistic care. A is incorrect as certification is not a requirement. B involves family inclusion but does not capture the core concept. C mentions collaboration but does not specifically address individualized care.
The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 12 5 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO ) of 90% on a 50% venturi mask. 2 Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pres sure (PAOP) of 3 mm Hg. The nurse questions which of the following primary health care provider’s order?
- A. Titrate supplemental oxygen to achieve a SpO > 94%a. birb.com/test
- B. Infuse 500 mL 0.9% normal saline over 1 hour.
- C. Obtain arterial blood gas and serum electrolytes.
- D. Administer furosemide 20 mg intravenously.
Correct Answer: D
Rationale: The correct answer is D: Administer furosemide 20 mg intravenously. In this scenario, the patient is hypotensive with a low cardiac output, low CVP, and low PAOP, indicating cardiogenic shock. Administering furosemide, a diuretic, can worsen the patient's condition by further decreasing preload. This can lead to a decrease in cardiac output and exacerbate the shock state. The other options are more appropriate:
A: Titrate supplemental oxygen to achieve a SpO > 94% - Correct, as improving oxygenation is essential in cardiogenic shock.
B: Infuse 500 mL 0.9% normal saline over 1 hour - Correct, as fluid resuscitation may be necessary to improve perfusion.
C: Obtain arterial blood gas and serum electrolytes - Correct, as these tests provide valuable information about the patient's oxygenation and electrolyte balance.
A nurse decides to seek certification in critical care nursing. What is the most important benefit for the individual nurse in becoming certified in a specialty?
- A. It will result in a salary increase.
- B. It is required to work in critical care.
- C. It demonstrates the nurses personal expertise.
- D. It is mandated by employers.
Correct Answer: C
Rationale: The correct answer is C because obtaining certification in critical care nursing demonstrates the nurse's personal expertise in the specialty. Certification confirms the nurse's advanced knowledge and skills, enhancing professional credibility and potential for career advancement. This choice focuses on the individual nurse's competency and dedication to the specialty.
Incorrect choices:
A: Salary increase is not the primary benefit of certification, although it may be a potential outcome.
B: Certification is often preferred but not always required to work in critical care.
D: Employers may encourage certification, but it is not always mandated.
The nurse is caring for a mechanically ventilated patient b eing monitored with a left radial arterial line. During the inspiratory phase of ventilation, th e nurse assesses a 20 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse?
- A. The mechanical ventilator is malfunctioning.
- B. The patient may require fluid resuscitation.
- C. The arterial line may need to be replaced.
- D. The left limb may have reduced perfusion.
Correct Answer: B
Rationale: The correct answer is B: The patient may require fluid resuscitation. A decrease in arterial blood pressure during the inspiratory phase of ventilation suggests decreased preload, indicating possible hypovolemia. This can be addressed by administering fluid resuscitation to improve cardiac output and blood pressure.
Incorrect Choices:
A: The mechanical ventilator is malfunctioning - There is no evidence to suggest a ventilator malfunction based on the arterial pressure change.
C: The arterial line may need to be replaced - The arterial line itself is unlikely to cause the observed pressure change.
D: The left limb may have reduced perfusion - This is less likely as the pressure change is likely systemic due to decreased preload.