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An intra-aortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met?
- A. Urine output of 25 mL/hr.
- B. Heart rate of 110 beats/minute.
- C. Cardiac output (CO) of 5 L/min.
- D. Stroke volume (SV) of 40 mL/beat.
Correct Answer: C
Rationale: The correct answer is C: Cardiac output (CO) of 5 L/min. In cardiogenic shock, the primary goal of using an IABP is to improve cardiac output to ensure adequate perfusion to vital organs. A cardiac output of 5 L/min indicates adequate blood flow and perfusion.
Choice A is incorrect as urine output is not a direct indicator of cardiac function. Choice B is incorrect as a heart rate of 110 beats/minute alone does not provide information on the effectiveness of the IABP in improving cardiac output. Choice D is incorrect as stroke volume alone does not provide a comprehensive assessment of overall cardiac function.
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The nurse is caring for a patient who has sustained blunt trauma to the left flank area, and is evaluating the patient’s urinalysis results. The nurse should become concerned when
- A. creatinine levels in the urine are similar to blood levels of creatinine.
- B. sodium and chloride are found in the urine.
- C. urine uric acid levels have the same values as serum levels.
- D. red blood cells and albumin are found in the urine.
Correct Answer: D
Rationale: The correct answer is D because the presence of red blood cells and albumin in the urine indicates possible kidney damage from the blunt trauma. This is concerning as it may suggest renal injury or dysfunction.
A: Creatinine levels in the urine being similar to blood levels is normal as creatinine is filtered by the kidneys.
B: Sodium and chloride being present in the urine is expected as they are components of urine.
C: Urine uric acid levels matching serum levels is common as uric acid is excreted by the kidneys.
In summary, the presence of red blood cells and albumin in the urine is abnormal and indicates potential kidney damage, making it the correct answer.
A middle-aged patient tells the nurse, 'My mother died 4 months ago, and I just can’t seem to get over it. I’m not sure it is normal to still think about her every day.' Which nursing diagnosis is most appropriate?
- A. Hopelessness related to the inability to resolve grief.
- B. Complicated grieving related to unresolved issues.
- C. Anxiety related to lack of knowledge about normal grieving.
- D. Chronic sorrow related to ongoing distress about the loss of a mother.
Correct Answer: C
Rationale: The correct answer is C: Anxiety related to lack of knowledge about normal grieving. This is because the patient is expressing uncertainty and seeking validation for their feelings, indicating a lack of understanding about the grieving process. Choice A is incorrect as hopelessness typically involves feelings of despair and loss of motivation, which are not explicitly stated by the patient. Choice B is incorrect as complicated grieving involves specific unresolved issues related to the loss, which the patient did not mention. Choice D is incorrect as chronic sorrow is typically associated with ongoing feelings of sadness and longing, which are not explicitly expressed by the patient.
Palliation care includes what goals? (Select all that apply.)
- A. Pain relief
- B. Nausea relief
- C. Psychological support
- D. Withdrawal of life-support interventions
Correct Answer: A
Rationale: The correct answer is A (Pain relief) because palliative care aims to provide comfort and improve the quality of life for individuals with serious illnesses. Pain relief is a crucial goal in palliative care to alleviate physical suffering. Nausea relief (B) is also commonly addressed in palliative care, but it is not a universal goal. Psychological support (C) is an important aspect of palliative care but is not always a primary goal. Withdrawal of life-support interventions (D) is not a goal of palliative care, as palliative care focuses on symptom management and improving quality of life, not hastening death.
Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict?
- A. Require the UAPs to reach a compromise.
- B. Weigh the consequences of each possible solution.
- C. Encourage the two to view the humor of the conflict.
- D. Deal with issues and not personalities.
Correct Answer: D
Rationale: The correct answer is D: Deal with issues and not personalities. This guideline is important because it focuses on resolving the conflict based on the actual problem at hand, rather than personal biases or emotions. By addressing the issues causing the argument, the nurse can help the UAPs find a fair and logical solution.
A: Requiring the UAPs to reach a compromise may not address the root cause of the conflict and could lead to further disagreements.
B: Weighing the consequences is important but may not be as effective in resolving the conflict as directly addressing the issues.
C: Encouraging humor may temporarily diffuse the situation but may not lead to a lasting resolution.
A client with osteoarthritis is given a new prescription for a nonsteroidal anti-inflammatory drug (NSAID). The client asks the nurse, 'How is this medication different from the acetaminophen I have been taking?' Which information about the therapeutic action of NSAIDs should the nurse provide?
- A. Are less expensive.
- B. Provide anti-inflammatory response.
- C. Increase hepatotoxic side effects.
- D. Cause gastrointestinal bleeding.
Correct Answer: B
Rationale: The correct answer is B: Provide anti-inflammatory response. NSAIDs work by inhibiting the enzyme cyclooxygenase, thereby reducing inflammation, pain, and fever. This is different from acetaminophen, which primarily acts as a pain reliever and fever reducer but lacks significant anti-inflammatory properties.
Explanation of why other choices are incorrect:
A: Are less expensive - Cost is not related to the therapeutic action of NSAIDs.
C: Increase hepatotoxic side effects - While NSAIDs can have adverse effects on the liver, hepatotoxicity is not a primary therapeutic action of these drugs.
D: Cause gastrointestinal bleeding - While NSAIDs can increase the risk of gastrointestinal bleeding, this is a potential side effect rather than the primary therapeutic action.