Nokea
Following surgery for an abdominal aortic aneurysm, the patient’s central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take?
- A. Administer IV diuretic medications.
- B. Increase the IV fluid infusion per protocol.
- C. Document the CVP and continue to monitor.
- D. Elevate the head of the patient's bed to 45 degrees.
Correct Answer: B
Rationale: The correct answer is B: Increase the IV fluid infusion per protocol. Low CVP post-abdominal aortic aneurysm surgery could indicate hypovolemia, which requires fluid resuscitation. Increasing IV fluid infusion helps restore intravascular volume, improve tissue perfusion, and prevent hypotension. Administering diuretics (A) would worsen hypovolemia. Documenting (C) is important but not the priority when the patient needs immediate intervention. Elevating the head of the bed (D) may help with venous return but is not the priority over addressing hypovolemia.
You may also like to solve these questions
In the critically ill patient, an incomplete assessment and/or management of pain or anxiety may be hampered by which of the following? (Select all that apply.)
- A. Administration of neuromuscular blocking agents
- B. Delirium
- C. Effective nurse communication and assessment skills
- D. Nonverbal patients
Correct Answer: A
Rationale: Step-by-step rationale:
1. Administration of neuromuscular blocking agents can hinder pain or anxiety assessment as it paralyzes the patient, preventing them from communicating discomfort.
2. Delirium may affect the patient's ability to express pain or anxiety, but it does not directly impede assessment and management.
3. Effective nurse communication and assessment skills facilitate, rather than hamper, pain or anxiety assessment.
4. Nonverbal patients can still communicate pain or anxiety through nonverbal cues, so they do not necessarily hinder assessment.
The patient diagnosed with acute respiratory distress synd rome (ARDS) would exhibit which symptom?
- A. Decreasing PaO levels despite increased FiO adminis tration
- B. Elevated alveolar surfactant levels
- C. Increased lung compliance with increased FiO administration 2
- D. Respiratory acidosis associated with hyperventilation
Correct Answer: A
Rationale: The correct answer is A because in ARDS, there is a severe impairment in gas exchange leading to hypoxemia. Decreasing PaO2 levels despite increased FiO2 administration indicate poor oxygenation, a hallmark of ARDS. Elevated alveolar surfactant levels (Choice B) do not directly correlate with ARDS pathophysiology. Increased lung compliance with increased FiO2 administration (Choice C) is not characteristic of ARDS, as ARDS leads to decreased lung compliance. Respiratory acidosis associated with hyperventilation (Choice D) is not a typical finding in ARDS, as hyperventilation is usually present in an attempt to compensate for hypoxemia.
Renin plays a role in blood pressure regulation by
- A. activating the renin-angiotensin-aldosterone cascade.
- B. suppressing angiotensin production.
- C. decreasing sodium reabsorption.
- D. inhibiting aldosterone release.
Correct Answer: A
Rationale: The correct answer is A because renin activates the renin-angiotensin-aldosterone cascade, which ultimately leads to vasoconstriction, increased blood pressure, and aldosterone release to increase sodium and water reabsorption. Renin does not suppress angiotensin production (B), decrease sodium reabsorption (C), or inhibit aldosterone release (D), as these actions would counteract its role in blood pressure regulation.
The nurse is caring for a mechanically ventilated patient an d responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarma, btihrbe.c nomu/rtesset assesses for which of the following? (Select all that apply.)
- A. Coughing or attempting to talk
- B. Disconnection from the ventilator
- C. Kinks in the ventilator tubing
- D. Need for suctioning
Correct Answer: B
Rationale: The correct answer is B: Disconnection from the ventilator. This is the correct choice because a high inspiratory pressure alarm can indicate a disconnection, leading to inadequate ventilation and increased pressure in the circuit. This can be a life-threatening situation that requires immediate attention.
Explanation of why other choices are incorrect:
A: Coughing or attempting to talk - While coughing or talking may affect the patient's ability to ventilate properly, it is not directly related to the high inspiratory pressure alarm.
C: Kinks in the ventilator tubing - Kinks in the tubing may cause increased resistance to airflow, but they are more likely to trigger a low pressure alarm rather than a high inspiratory pressure alarm.
D: Need for suctioning - Suctioning may be necessary for airway clearance, but it is not directly related to the high inspiratory pressure alarm.
Which of the following professional organizations best supports critical care nursing practice?
- A. American Association of Critical-Care Nurses
- B. American Heart Association
- C. American Nurses Association
- D. Society of Critical Care Medicine
Correct Answer: A
Rationale: The correct answer is A: American Association of Critical-Care Nurses (AACN). This organization focuses exclusively on critical care nursing, offering specialized education, resources, and certifications for critical care nurses. AACN advocates for high standards of care in critical care settings. The other choices do not specifically cater to critical care nursing practice. The American Heart Association focuses on cardiovascular health, the American Nurses Association is a general nursing organization, and the Society of Critical Care Medicine is more physician-centric. Therefore, A is the best choice for supporting critical care nursing practice.