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In assessing a patient, the nurse understands that what sym ptomology is an early sign of hypoxemia?
- A. Clubbing of nail beds
- B. Cyanosis
- C. Hypotension
- D. Restlessness
Correct Answer: D
Rationale: Step 1: Restlessness is an early sign of hypoxemia due to the body's response to low oxygen levels.
Step 2: Restlessness occurs as the body tries to increase oxygen intake.
Step 3: Other choices are incorrect because clubbing and cyanosis are late signs, while hypotension is not a specific early sign of hypoxemia.
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Which findings have been reported in the literature as benefits of allowing family to be present during resuscitation and invasive procedures? (Selaebcirtb a.clolm t/hteastt apply.)
- A. Families benefit by witnessing that everything possible was done.
- B. Families report reduced anxiety and fear about what is being done to the patient.
- C. Presence encourages family members to seek litigation for improper care.
- D. Presence reduces nurses’ involvement in explaining th ings to the family.
Correct Answer: A
Rationale: Step 1: Families benefit by witnessing that everything possible was done during resuscitation and invasive procedures.
Step 2: This reassures families that healthcare providers are doing their best to save the patient.
Step 3: It can provide closure and comfort to families knowing that all efforts were made.
Step 4: This transparency can also help in the grieving process for families.
Summary: Choice A is correct because it highlights the emotional and psychological benefits for families. Choices B, C, and D are incorrect as they do not align with the positive impacts of allowing family presence during resuscitation and invasive procedures.
As the nurse admits a patient with end-stage kidney disease to the hospital, the patient tells the nurse, 'If my heart or breathing stops, I do not want to be resuscitated.' Which action is best for the nurse to take?
- A. Ask if these wishes have been discussed with the healthcare provider.
- B. Place a Do Not Resuscitate (DNR) notation in the patient’s care plan.
- C. Inform the patient that a notarized advance directive must be included in the record.
- D. Advise the patient to designate a person to make health care decisions.
Correct Answer: A
Rationale: Step 1: Asking if these wishes have been discussed with the healthcare provider is important to ensure that the patient's wishes are documented and considered in the care plan.
Step 2: The healthcare provider needs to be aware of the patient's preferences regarding resuscitation to provide appropriate care.
Step 3: This step helps in clarifying the patient's preferences and ensures that the healthcare team follows the patient's wishes.
Step 4: Placing a DNR notation without consulting the healthcare provider may not align with the patient's overall care plan and may lead to potential legal and ethical issues.
Step 5: Informing the patient about notarized advance directives and designating a person for healthcare decisions are important but not the immediate step needed in this scenario.
In summary, choice A is correct as it prioritizes communication with the healthcare provider to ensure the patient's wishes are properly documented and followed. Choices B, C, and D are incorrect because they do not involve confirming the patient's wishes
The nurse is caring for a terminally ill patient who has chosen palliative care. Which goal should the nurse prioritize when planning care?
- A. Cure the patient’s underlying disease.
- B. Manage the patient’s pain and symptoms.
- C. Prolong the patient’s life expectancy.
- D. Address the family’s concerns and questions.
Correct Answer: B
Rationale: The correct answer is B: Manage the patient's pain and symptoms. In palliative care, the primary goal is to provide comfort and improve quality of life for terminally ill patients. Managing pain and symptoms is crucial in achieving this goal. By addressing pain and symptoms, the nurse can help enhance the patient's comfort and well-being. Other choices are incorrect because palliative care focuses on improving quality of life rather than curing the underlying disease (A), prolonging life expectancy (C), or primarily addressing family concerns (D). Prioritizing pain and symptom management aligns with the holistic approach of palliative care.
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.
What are the diagnostic criteria for acute respiratory distress syndrome (ARDS)? (Select all that apply.)
- A. Bilateral infiltrates on chest x-ray study
- B. Decreased cardiac output
- C. PaO /FiO ratio of less than 200 2 2
- D. Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg
Correct Answer: A
Rationale: The correct answer is A: Bilateral infiltrates on chest x-ray study. ARDS diagnosis requires bilateral infiltrates on chest x-ray, indicative of non-cardiogenic pulmonary edema. Choice B, decreased cardiac output, is not a diagnostic criterion for ARDS. Choice C, PaO2/FiO2 ratio of less than 200, is a key diagnostic criteria for ARDS, indicating severe hypoxemia. Choice D, PAOP of more than 18 mm Hg, is used to differentiate between cardiogenic and non-cardiogenic causes of pulmonary edema, but it is not a direct diagnostic criterion for ARDS.