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The charge nurse is supervising the care of four critical ca re patients being monitored using invasive hemodynamic modalities. Which patient should t he charge nurse evaluate first?
- A. A patient in cardiogenic shock with a cardiac output (CabOirb). coofm 2/te.0st L/min
- B. A patient with a pulmonary artery systolic pressure (PA P) of 20 mm Hg
- C. A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg
- D. A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg
Correct Answer: A
Rationale: The correct answer is A because the patient in cardiogenic shock with a cardiac output of 2.0 L/min is experiencing a life-threatening condition that requires immediate evaluation. Cardiogenic shock indicates poor cardiac function, which can lead to multi-organ failure. Monitoring cardiac output is crucial in managing these patients.
Choice B is incorrect because a pulmonary artery systolic pressure of 20 mm Hg is within normal range and does not indicate an immediate life-threatening condition.
Choice C is incorrect because a CVP of 6 mm Hg in a hypovolemic patient may indicate volume depletion, but it is not as urgent as the patient in cardiogenic shock.
Choice D is incorrect because a PAOP of 10 mm Hg is within normal range and does not suggest an immediate critical condition.
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The nurse recommends that the family of a critically ill patient seek help from the Critical Care Family Assistance Program. What benefit for the family does the nurse anticipate?
- A. Reduction of health care cost
- B. More physical comfort
- C. Multidisciplinary support
- D. Health promotion information
Correct Answer: C
Rationale: The correct answer is C: Multidisciplinary support. The Critical Care Family Assistance Program offers a range of professionals such as social workers, counselors, and financial advisors to provide holistic support to the family. This helps address emotional, financial, and practical needs during a challenging time. Option A is incorrect because the program does not directly reduce healthcare costs. Option B is incorrect as the focus is not solely on physical comfort but on comprehensive support. Option D is incorrect as the primary aim is not health promotion but rather addressing the family's immediate concerns and needs.
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.
Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? (Select all that apply.)
- A. Hypotension
- B. Dysrhythmias
- C. Muscle cramps
- D. Hemolysis
Correct Answer: A
Rationale: The correct answer is A, hypotension. During hemodialysis for acute kidney injury, fluid removal can lead to hypotension due to rapid changes in blood volume. This can cause dizziness, weakness, and even loss of consciousness. Dysrhythmias (choice B) are less common but can occur due to electrolyte imbalances. Muscle cramps (choice C) may occur during or after dialysis due to electrolyte imbalances or fluid shifts, but they are not as common as hypotension. Hemolysis (choice D) is not a common complication of hemodialysis for acute kidney injury, as it is more commonly associated with issues related to the dialysis machine or blood tubing.
A nurse who works in an intermediate care unit has experienced high nursing turnover. The nurse manager is often considered to be an autocratic leade r by staff members and that leadership style is contributing to turnover. The nurse asks to be involved in developing new guidelines to prevent pressure ulcers in the patient populat ion. The nurse manager suggests that the nurse has not yet had enough experience to be on tahbierb p.croemv/teenstt ion task force. This situation and setting is an example of what form of ineffec tive leadership?
- A. Creating a barrier to inter-staff communication.
- B. Supporting a work environment that is unhealthy.
- C. Displaying ineffective decision making.
- D. Demonstrating nursing practice that is not evidence-based.
Correct Answer: C
Rationale: The correct answer is C: Displaying ineffective decision making. In this scenario, the nurse manager's decision to exclude the nurse from participating in developing new guidelines is an example of ineffective decision making. By dismissing the nurse's request based on lack of experience rather than considering their input and involvement, the manager is not utilizing the nurse's expertise and potentially missing out on valuable insights. This decision reflects a lack of inclusivity, collaboration, and respect for the nurse's professional growth and potential contributions. The other choices are not directly applicable in this context as the core issue lies in the manager's decision-making process.
The intensive care unit (ICU) nurse educator will determine that teaching arterial pressure monitoring to staff nurses has been effective when the nurse:
- A. Balances and calibrates the monitoring equipment every 2 hours.
- B. Positions the zero-reference stopcock line level with the hemostatic axis.
- C. Ensures that the patient is supine with the head of the bed flat for all readings.
- D. Rechecks the location of the hemostatic axis when changing the patient’s position.
Correct Answer: B
Rationale: The correct answer is B because positioning the zero-reference stopcock line level with the hemostatic axis ensures accurate arterial pressure monitoring. Placing the stopcock at the hemostatic axis allows for correct measurement of blood pressure without any errors due to height differences. This positioning helps in obtaining precise and reliable readings.
A: Balancing and calibrating the monitoring equipment every 2 hours is important for equipment maintenance but does not directly impact the accuracy of arterial pressure monitoring.
C: Ensuring the patient is supine with the head of the bed flat is a standard position for arterial pressure monitoring but does not specifically address the correct positioning of the stopcock.
D: Rechecking the location of the hemostatic axis when changing the patient's position is essential for maintaining accuracy, but it does not directly relate to the initial correct positioning of the stopcock.