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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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A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma?
- A. Carteolol (Ocupress)
- B. Propranolol hydrochloride (Inderal)
- C. Pindolol (Visken)
- D. Metoprolol tartrate (Lopressor)
Correct Answer: D
Rationale: The correct answer is D, Metoprolol tartrate (Lopressor). Metoprolol is a cardioselective beta-blocker that primarily targets beta-1 receptors in the heart, making it less likely to exacerbate asthma compared to non-selective beta-blockers like Propranolol (choice B) and Pindolol (choice C). Carteolol (choice A) is also a non-selective beta-blocker and can potentially worsen asthma symptoms. Metoprolol's selectivity for beta-1 receptors minimizes bronchoconstriction, making it the safest choice for a client with asthma and high blood pressure.
A nurse is the only one in the ICU who has not achieved certification in critical care nursing. She often will ask her fellow nurses what to do in caring for a patient because she doubts the accuracy of her knowledge and her intuition. She loves her work but wishes she could do it with a greater level of competence. What is the most important effect that obtaining certification would likely have on the nurses practice?
- A. Recognition by peers
- B. Increase in salary and rank
- C. More flexibility in seeking employment
- D. Increased confidence in making decisions
Correct Answer: D
Rationale: The correct answer is D: Increased confidence in making decisions. Obtaining certification in critical care nursing would likely enhance the nurse's knowledge and skills, leading to increased confidence in making clinical decisions. This confidence would stem from the rigorous training and education required to achieve certification, as well as the validation of her expertise in critical care nursing. With increased confidence, the nurse would be more self-assured in her abilities, leading to improved patient care outcomes.
Choice A: Recognition by peers is not the most important effect because while recognition is a positive outcome, it may not directly impact the nurse's ability to provide better patient care.
Choice B: Increase in salary and rank is not the most important effect because while financial benefits are important, the primary focus of obtaining certification should be on improving competence and patient care.
Choice C: More flexibility in seeking employment is not the most important effect because while certification may open up more job opportunities, the main benefit should be on enhancing the nurse's skills and confidence in providing quality
The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will be most effective in addressing this problem?
- A. Increase suctioning to every hour.
- B. Reposition the patient every 1 to 2 hours.
- C. Add additional water to the patient’s enteral feedings.
- D. Instill 5 mL of sterile saline into the ET before suctioning.
Correct Answer: D
Rationale: The correct answer is D: Instill 5 mL of sterile saline into the ET before suctioning. This intervention helps to loosen and mobilize the thick secretions, making them easier to remove during suctioning. It is important to moisten the secretions to prevent mucosal damage and trauma during suctioning.
A: Increasing suctioning frequency can lead to mucosal damage and increased risk of infection.
B: Repositioning helps with ventilation and preventing pressure injuries, but it does not directly address the thick secretions.
C: Adding water to enteral feedings will not directly address the thick secretions in the ET.
In summary, instilling sterile saline into the ET before suctioning is the most effective intervention as it helps to loosen and mobilize thick secretions, making suctioning more effective and reducing the risk of mucosal damage.
Which action is a priority for the nurse to take when the low-pressure alarm sounds for a patient who has an arterial line in the left radial artery?
- A. Fast flush of the arterial line.
- B. Check the left hand for pallor.
- C. Assess for cardiac dysrhythmias.
- D. Rezero the monitoring equipment.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): When the low-pressure alarm sounds for a patient with an arterial line, the nurse should assess for cardiac dysrhythmias first. This is because a sudden drop in pressure could indicate a serious issue affecting the heart's ability to pump effectively. Identifying and addressing any cardiac dysrhythmias promptly is crucial for patient safety.
Summary of Incorrect Choices:
A: Fast flush of the arterial line - This would not address the underlying cause of the low-pressure alarm and may not be necessary.
B: Check the left hand for pallor - While assessing perfusion is important, it is not the priority when the alarm indicates a potential cardiac issue.
D: Rezero the monitoring equipment - While important for accuracy, it is not the priority when the alarm indicates a potential cardiac concern.
What is a minimally acceptable urine output for a patient weighing 75 kg?
- A. Less than 30 mL/hour
- B. 37 mL/hour
- C. 80 mL/hour
- D. 150 mL/hour
Correct Answer: C
Rationale: The correct answer is C (80 mL/hour) because the minimum acceptable urine output for a patient is approximately 0.5-1 mL/kg/hour. For a 75 kg patient, this equates to 37.5-75 mL/hour. Therefore, an output of 80 mL/hour is within this range and is considered minimally acceptable.
A: Less than 30 mL/hour is incorrect because it is below the recommended range for a 75 kg patient.
B: 37 mL/hour is close to the lower end of the acceptable range, but it is not the minimum acceptable output.
D: 150 mL/hour is above the recommended range and would be considered excessive for a 75 kg patient.