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The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2, the nurse assesses the patient’s:
- A. Lipase.
- B. Temperature.
- C. Urinary output.
- D. Body mass index.
Correct Answer: B
Rationale: The correct answer is B: Temperature. Decreased ScvO2 in severe pancreatitis can be due to systemic inflammatory response leading to increased metabolic demand and decreased tissue oxygen delivery. Monitoring temperature helps assess for presence of infection or sepsis, which can further decrease tissue oxygenation. Lipase (A) is specific for pancreatitis diagnosis, not directly related to ScvO2. Urinary output (C) is important for assessing renal function, not directly related to ScvO2. Body mass index (D) does not provide information on tissue oxygenation status in this context.
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The nurse caring for a patient with an endotracheal tube un derstands that endotracheal suctioning is needed to facilitate removal of secretions. What additional information is the nurse aware of concerning this intervention?
- A. It decreases intracranial pressure.
- B. It depresses the cough reflex.
- C. It is done as indicated by patient assessment.
- D. It is more effective if preceded by saline instillation to loosen secretions.
Correct Answer: C
Rationale: Rationale for Correct Answer C: Endotracheal suctioning should be done as indicated by patient assessment because not all patients require routine suctioning. Performing unnecessary suctioning can lead to potential complications such as mucosal damage and increased risk of infection. Therefore, the nurse must assess the patient's respiratory status, auscultate lung sounds, monitor oxygen saturation levels, and observe for signs of increased secretions before deciding to perform suctioning.
Summary of Incorrect Choices:
A: Endotracheal suctioning does not directly impact intracranial pressure. It is primarily focused on maintaining airway patency and removing respiratory secretions.
B: While endotracheal suctioning may temporarily suppress the cough reflex during the procedure, its primary purpose is to clear airway secretions to prevent complications such as atelectasis and respiratory distress.
D: Saline instillation before suctioning is not recommended as it can lead to negative outcomes such as dehydration, mucosal damage, and increased risk of infection
The client has been in the CCU for several weeks and has been very unstable. One family member stays at the bedside constantly and even naps in a bedside chair. The nurse understands that the family member is exhibiting which family member response to critical illness?
- A. Exhibiting extreme distrust of the health care team
- B. Seeking evidence for future legal or punitive action
- C. Trying to maintain a level of control over the situation
- D. Experiencing extreme fatigue from constant stress
Correct Answer: C
Rationale: The correct answer is C: Trying to maintain a level of control over the situation. The family member staying at the bedside constantly and even napping there is likely trying to cope with the stressful situation by maintaining a sense of control and connection to the patient. This behavior can be a way for the family member to feel more involved and helpful during a time of uncertainty and powerlessness. Choices A and B involve negative assumptions about the family member's intentions without evidence. Choice D may be a result of the family member's actions but does not address the underlying motivation for their behavior.
The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues?
- A. Arterial lactate level of 1.0 mEq/L
- B. Cardiac output of 2.5 L/min
- C. Mixed venous (SvO ) of 40%
- D. Cardiac index of 1.5 L/min/m2
Correct Answer: C
Rationale: The correct answer is C: Mixed venous (SvO2) of 40%. In septic shock, improving oxygen delivery to tissues is vital. SvO2 reflects the balance between oxygen delivery and consumption. A value of 40% indicates adequate oxygen delivery to tissues.
A: Arterial lactate level of 1.0 mEq/L - Although a low lactate level is good, it does not directly indicate improved oxygen delivery.
B: Cardiac output of 2.5 L/min - Cardiac output should ideally increase to improve oxygen delivery, so 2.5 L/min is low for a 70-kg patient.
D: Cardiac index of 1.5 L/min/m2 - Cardiac index is cardiac output adjusted for body surface area. 1.5 L/min/m2 is low and indicates inadequate cardiac function for a patient in septic shock.
What is the main purpose of certification for critical care n ursing?
- A. To assure the consumer that critical nurses will not make a mistake.
- B. To help prepare the critical care nurse for graduate sch ool.
- C. To assist in promoting magnet status for a facility.
- D. To validate a nurse’s knowledge of critical care nursing
Correct Answer: D
Rationale: The correct answer is D: To validate a nurse’s knowledge of critical care nursing. Certification in critical care nursing validates a nurse's expertise and knowledge in this specialized area of nursing. It demonstrates that the nurse has met certain standards and competencies in critical care practice. This certification ensures that the nurse is well-equipped to provide high-quality care to critically ill patients.
A: To assure the consumer that critical nurses will not make a mistake - This choice is incorrect because certification does not guarantee that nurses will not make mistakes. It focuses on validating knowledge and skills rather than infallibility.
B: To help prepare the critical care nurse for graduate school - This choice is incorrect as certification is more focused on practice readiness rather than academic preparation.
C: To assist in promoting magnet status for a facility - This choice is incorrect as magnet status relates more to the overall excellence and quality of nursing care in a facility, not individual certification.
While caring for a critically ill patient, the nurse knows that fostering patient control over the environment is a method for stress reduction. What nursing intervention gives the patient the most environmental control while still adhering to best practice principles?
- A. Ask the patient whether he or she wants to get out of bed.
- B. Give the patients bath at the same time every day.
- C. Explain painful procedures only after giving pain medication.
- D. Choose menu items for the patient to ensure a balanced diet.
Correct Answer: A
Rationale: Step 1: Asking the patient whether he or she wants to get out of bed allows the patient to make a decision regarding their immediate environment, promoting autonomy and control.
Step 2: This intervention respects the patient's preferences and fosters a sense of dignity and empowerment, reducing stress.
Step 3: Best practice principles in nursing emphasize patient-centered care and promoting patient autonomy.
Summary:
Choice A is correct as it directly involves the patient in decision-making, enhancing their sense of control. Choices B, C, and D do not provide the same level of autonomy and control to the patient, making them less effective in reducing stress and promoting patient well-being.