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The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action?
- A. Diminished breath sounds over left lung field
- B. Localized pain at catheter insertion site
- C. Measured central venous pressure of 5 mm Hg
- D. Slight bloody drainage around insertion site
Correct Answer: A
Rationale: The correct answer is A: Diminished breath sounds over the left lung field. This finding could indicate a pneumothorax, a serious complication of subclavian CVC insertion. Immediate action is required to prevent respiratory distress.
Incorrect answers:
B: Localized pain at insertion site is common post-procedure and may not indicate a serious issue.
C: A central venous pressure of 5 mm Hg is within the normal range and does not require immediate action.
D: Slight bloody drainage is expected initially and can be managed with routine care.
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A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped?
- A. The patient’s heart rate is 97 beats/min.
- B. The patient’s oxygen saturation is 93%.
- C. The patient’s respiratory rate is 32 breaths/min.
- D. The patient’s spontaneous tidal volume is 450 mL.
Correct Answer: C
Rationale: The correct answer is C because a respiratory rate of 32 breaths/min indicates increased work of breathing, which could be a sign of respiratory distress. In a patient being weaned from mechanical ventilation, an elevated respiratory rate suggests that the patient may not be able to sustain adequate ventilation on their own. This warrants stopping the weaning protocol to prevent respiratory failure.
Choice A is incorrect because a heart rate of 97 beats/min is within normal range for an adult. Choice B is incorrect because an oxygen saturation of 93% is acceptable for a patient with COPD. Choice D is incorrect because a tidal volume of 450 mL is adequate for a patient weaning from mechanical ventilation.
A nurse is on a committee that is trying to reduce the occurrence of hospital-acquired infections in the ICU. Her role is to conduct research to find which interventions have been shown to be most effective in reducing these infections. She consults many different sources and finds conflicting information. Which of the following sources should she consider the most authoritative?
- A. AACN expert panel report
- B. A meta-analysis of randomized controlled trials in the American Journal of Nursing
- C. A systematic review of qualitative studies in the Journal of Advanced Nursing
- D. A single randomized controlled trial in the American Journal of Critical Care
Correct Answer: B
Rationale: The correct answer is B: A meta-analysis of randomized controlled trials in the American Journal of Nursing.
1. Meta-analyses provide a comprehensive overview of multiple studies, increasing the reliability of the findings.
2. Randomized controlled trials are considered the gold standard in research design for assessing intervention effectiveness.
3. The American Journal of Nursing is a reputable source in the field of nursing, ensuring the credibility of the study.
4. By synthesizing data from various trials, the meta-analysis can offer a more robust and generalizable conclusion compared to a single trial or qualitative studies.
Incorrect choices:
A: AACN expert panel report - Expert opinions may vary and lack the empirical evidence provided by research studies.
C: A systematic review of qualitative studies in the Journal of Advanced Nursing - Qualitative studies may provide valuable insights but may not offer concrete evidence on intervention effectiveness like quantitative studies.
D: A single randomized controlled trial in the American Journal of Critical Care - Single trials may not capture the full picture and
The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis?
- A. Glasgow Coma Scale score of 3
- B. Train-of-four yields two twitches
- C. Bispectral index of 60
- D. CAM-ICU positive
Correct Answer: B
Rationale: The correct answer is B: Train-of-four yields two twitches. This assessment indicates a target level of paralysis because a train-of-four ratio of 2 twitches out of 4 suggests a 50% neuromuscular blockade, which is often the goal for patients receiving paralysis for procedures or ventilation.
A: A Glasgow Coma Scale score of 3 assesses consciousness, not neuromuscular blockade.
C: A Bispectral index of 60 measures depth of anesthesia, not paralysis level.
D: CAM-ICU assesses delirium, not neuromuscular blockade.
Which intervention is appropriate to assist the patient to co pe with admission to the critical care unit?
- A. Allowing unrestricted visiting by several family members at one time
- B. Explaining all procedures in easy-to-understand terms
- C. Providing back massage and mouth care
- D. Turning down the alarm volume on the cardiac monito r
Correct Answer: B
Rationale: The correct answer is B: Explaining all procedures in easy-to-understand terms. This intervention is appropriate as it helps reduce the patient's anxiety by providing clear information about what to expect during their stay in the critical care unit. This promotes a sense of control and understanding, which can positively impact the patient's coping mechanisms.
A: Allowing unrestricted visiting by several family members at one time may overwhelm the patient and interfere with their rest and recovery.
C: Providing back massage and mouth care may be beneficial but may not directly address the patient's need for information and understanding.
D: Turning down the alarm volume on the cardiac monitor may provide a more comfortable environment but does not address the patient's emotional and psychological needs related to coping with admission to the critical care unit.
What factors may predispose a patient to respiratory acido as bi is rb? . com/test
- A. Anxiety and fear
- B. Central nervous system depression
- C. Diabetic ketoacidosis
- D. Nasogastric suctioning
Correct Answer: B
Rationale: The correct answer is B: Central nervous system depression. This factor can lead to respiratory acidosis by depressing the respiratory drive, causing hypoventilation and retention of carbon dioxide. Anxiety and fear (A) may lead to hyperventilation, reducing carbon dioxide levels. Diabetic ketoacidosis (C) results in metabolic acidosis, not respiratory acidosis. Nasogastric suctioning (D) may cause respiratory alkalosis from excessive removal of carbon dioxide. Thus, central nervous system depression is the most likely factor predisposing a patient to respiratory acidosis.