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Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department (ED). Which patient will the nurse need to assess first?
- A. A patient with a red tag.
- B. A patient with a blue tag.
- C. A patient with a black tag.
- D. A patient with a yellow tag.
Correct Answer: A
Rationale: The correct answer is A: A patient with a red tag. In triage, red tags indicate patients with life-threatening injuries who require immediate attention. The nurse must assess this patient first to provide necessary interventions. Patients with blue tags are considered urgent but stable, black tags are deceased or beyond help, and yellow tags are for delayed treatment. Assessing the red-tagged patient first ensures prompt care for those in critical condition.
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The patient has elevated blood urea nitrogen (BUN) and serum creatinine levels with a normal BUN/creatinine ratio. These levels most likely indicate
- A. increased nitrogen intake.
- B. acute kidney injury, such as acute tubular necrosis (ATN).
- C. hypovolemia.
- D. fluid resuscitation.
Correct Answer: B
Rationale: The elevated BUN and creatinine levels with a normal BUN/creatinine ratio indicate impaired kidney function. This pattern is commonly seen in acute kidney injury, such as acute tubular necrosis (ATN). In ATN, there is damage to the renal tubules leading to decreased excretion of waste products, resulting in elevated BUN and creatinine levels. The normal BUN/creatinine ratio suggests that the impairment is due to renal tubular dysfunction rather than prerenal causes like hypovolemia or postrenal causes like urinary obstruction. Increased nitrogen intake would not produce this specific pattern of results. Fluid resuscitation would likely result in dilution of BUN and creatinine levels, leading to lower values.
Family assessment can be challenging and each nurse may obtain additional information regarding family structure and dynamics. What is the best way to share this information from shift to shift?
- A. Create an informal family information sheet that is kept on the bedside clipboard. That way, everyone can review it quickly when needed .
- B. Develop a standardized reporting form for family infora mbir ab. tc io om n/ te thst a t is incorporated into the patient’s medical record and updated as neede d.
- C. Require that the charge nurse have a detailed list of inf ormation about each patient and family member. Thus, someone on the unit is always knowledgeable about potential issues.
- D. Try to remember to discuss family structure and dynamics as part of the change-of-shift report.
Correct Answer: B
Rationale: The correct answer is B because developing a standardized reporting form for family information that is incorporated into the patient's medical record ensures consistency and accuracy in sharing vital details about family structure and dynamics from shift to shift. This method allows all healthcare providers to access the information easily and update it as needed, promoting continuity of care and comprehensive understanding of the family's needs.
Choices A, C, and D are incorrect because:
A: Creating an informal family information sheet may lead to inconsistencies in the information shared among healthcare providers and may not be updated regularly.
C: Requiring only the charge nurse to have detailed information may result in information silos and lack of accessibility for all team members.
D: Discussing family dynamics as part of the change-of-shift report may lead to important details being missed or forgotten, compromising the quality of care provided.
As part of the admission process, the nurse asks several questions about family relationships. The nurse bases these actions on which rationale?
- A. Assessing family relationships is an initial step in including the family in patient care.
- B. These questions are part of the admission assessment tool required by this CCU.
- C. The nurse has a natural curiosity and wishes to know how the family members relate for her own knowledge.
- D. There is an ongoing research study to identify variant family patterns related to disease incidence.
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. Involving the family in patient care is crucial for holistic care.
2. Assessing family relationships helps identify support systems and potential conflicts.
3. Understanding family dynamics aids in creating a comprehensive care plan.
4. Family involvement can enhance patient outcomes and satisfaction.
Summary of incorrect choices:
B. Irrelevant, as the focus is on patient-centered care, not just fulfilling an assessment tool.
C. Personal curiosity is not a valid reason for assessing family relationships in healthcare.
D. Conducting research on family patterns does not directly impact the immediate care of the patient.
The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is mechanically ventilated. Ensuring that the aaibri-rbf.lcuoimd/ teinstt erface is at the level of the phlebostatic axis, what is the best nursing action?
- A. Place the patient in the supine position and record the PAOP immediately after exhalation.
- B. Place the patient in the supine position and document the average PAOP obtained after three measurements.
- C. Place the patient with the head of bed elevated 30 degrees and document the average PAOP pressure obtained.
- D. Place the patient with the head of bed elevated 30 degr ees and record the PAOP just before the increase in pressures during inhalation.
Correct Answer: C
Rationale: The correct answer is C because placing the patient with the head of the bed elevated 30 degrees is the best position for obtaining an accurate PAOP reading. Elevating the head of the bed helps to align the phlebostatic axis with the atrium, ensuring an accurate measurement of PAOP. This position reduces the impact of hydrostatic pressure on the reading. Options A and D are incorrect because the supine position and recording during exhalation or just before the increase in pressures during inhalation can lead to inaccurate readings. Option B is incorrect because documenting the average PAOP after three measurements does not address the importance of positioning for accuracy.
The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education?
- A. The RN increases the FIO2 to 100% before suctioning.
- B. The RN secures a bite block in place using adhesive tape.
- C. The RN asks for assistance to reposition the endotracheal tube.
- D. The RN positions the patient with the head of the bed at 10 degrees.
Correct Answer: D
Rationale: The correct answer is D because positioning the patient with the head of the bed at 10 degrees is incorrect for a patient receiving mechanical ventilation. The optimal position for such patients is to elevate the head of the bed to 30-45 degrees to prevent aspiration and improve oxygenation. Option A is incorrect as increasing FIO2 before suctioning is appropriate to ensure adequate oxygenation. Option B is incorrect as securing a bite block in place using adhesive tape is a standard practice to prevent the patient from biting on the endotracheal tube. Option C is incorrect as asking for assistance to reposition the endotracheal tube shows the RN is aware of the importance of proper placement to ensure effective ventilation.