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When caring for a patient with a pulmonary artery (PA) pressure catheter, the nurse observes that the PA waveform indicates that the catheter is in the wedged position. Which action should the nurse take next?
- A. Zero balance the transducer.
- B. Activate the fast flush system.
- C. Notify the health care provider.
- D. Deflate and reinflate the PA balloon.
Correct Answer: C
Rationale: The correct answer is C: Notify the health care provider. When the PA waveform indicates the catheter is in the wedged position, it means the catheter tip is in the pulmonary artery, potentially causing complications. The nurse should notify the healthcare provider immediately to assess and reposition the catheter to prevent further issues. Zero balancing the transducer (A) or activating the fast flush system (B) are not appropriate actions for this situation. Deflating and reinflating the PA balloon (D) could exacerbate the issue and should only be done under the guidance of the healthcare provider.
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A 65-year-old patient admitted to the progressive care unit with a diagnosis of community-acquired pneumonia, has a history of chronic obstructive pulmonary disease and diabetes. A set of arterial blood gases obtained on admissiaobnir bw.coitmh/oteustt supplemental oxygen shows pH 7.35; PaCO 55 mm Hg; bicarbonate 30 mEq/L ; PaO 65 mm Hg. These blood 2 2 gases reflect what condition?
- A. Hypoxemia and compensated metabolic alkalosis.
- B. Hypoxemia and compensated respiratory acidosis.
- C. Normal oxygenation and partly compensated metaboli c alkalosis.
- D. Normal oxygenation and uncompensated respiratory acidosis.
Correct Answer: B
Rationale: The correct answer is B: Hypoxemia and compensated respiratory acidosis. The patient's pH is within normal range (7.35), indicating compensation. The elevated PaCO2 (55 mm Hg) indicates respiratory acidosis due to inadequate ventilation, likely from COPD. The low PaO2 (65 mm Hg) indicates hypoxemia, common in pneumonia. The normal bicarbonate level (30 mEq/L) suggests metabolic compensation for respiratory acidosis. Choice A is incorrect as there is no metabolic alkalosis present. Choice C is incorrect as the patient has hypoxemia. Choice D is incorrect as the patient is showing compensated respiratory acidosis, not uncompensated.
A patient in a critical care unit has increased stress from the constant noise and light levels. What nursing intervention best attenuates these sources of stress?
- A. Need for constant observation and evaluation
- B. Dimming lights during the night
- C. Frequent nursing group rounds for all patients
- D. Use of tile floors for ease in cleaning
Correct Answer: B
Rationale: The correct answer is B: Dimming lights during the night. This intervention helps reduce stress by creating a more calming environment, promoting rest and sleep. Constant observation (choice A) may increase stress due to lack of privacy. Frequent group rounds (choice C) may disrupt rest. Use of tile floors (choice D) is unrelated to addressing noise and light stress.
The critical care environment is stressful to the patient. Which interventions assist in reducing this stress? (Select all that apply.)
- A. Adjust lighting to promote normal sleep-wake cycles.
- B. Provide clocks, calendars, and personal photos in the p atient’s room.
- C. Talk to the patient about other patients you are caring for on the unit.
- D. Tell the patient the day and time when you are providi ng routine nursing interventions.
Correct Answer: A
Rationale: Correct Answer: A. Adjust lighting to promote normal sleep-wake cycles.
Rationale:
1. Adjusting lighting can help regulate the patient's circadian rhythm, promoting better sleep and reducing stress.
2. Normal sleep-wake cycles are crucial for overall well-being and healing in a critical care setting.
3. Proper lighting can also create a more calming environment for the patient.
Summary of Incorrect Choices:
B. Providing clocks, calendars, and personal photos can be overwhelming for a stressed patient.
C. Talking about other patients may increase anxiety and breach patient confidentiality.
D. Telling the day and time of routine interventions may disrupt the patient's sense of time and add to stress.
Which statement is true regarding venous thromboembolisambir b(.VcoTm/Ete)s ta nd pulmonary embolus (PE)?
- A. PE should be suspected in any patient who has unexpla ined cardiorespiratory complaints and risk factors for VTE.
- B. Bradycardia and hyperventilation are classic symptom s of PE.
- C. Dyspnea, chest pain, and hemoptysis occur in nearly a ll patients with PE.
- D. Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis.
Correct Answer: A
Rationale: The correct answer is A because PE should be suspected in patients with unexplained cardiorespiratory complaints and risk factors for VTE. This is important because PE can present with nonspecific symptoms, making it crucial to consider it in the differential diagnosis.
Explanation:
1. PE can present with various symptoms, including dyspnea, chest pain, and hemoptysis, but these are not present in all patients.
2. Bradycardia and hyperventilation are not classic symptoms of PE, as it can present with tachycardia and other respiratory findings.
3. Critically ill patients are actually at higher risk for VTE and PE, so prophylaxis is typically recommended.
In summary, choice A is correct because it emphasizes the importance of considering PE in patients with cardiorespiratory complaints and risk factors for VTE, while the other choices contain inaccuracies or incomplete information.
The nurse notes that a patient’s endotracheal tube (ET), which was at the 22 cm mark, is now at the 25 cm mark and the patient is anxious and restless. Which action should the nurse take next?
- A. Offer reassurance to the patient.
- B. Bag the patient at an FIO2 of 100%.
- C. Listen to the patient’s breath sounds.
- D. Notify the patient’s health care provider.
Correct Answer: C
Rationale: The correct answer is C: Listen to the patient’s breath sounds. Moving from 22 cm to 25 cm may indicate ET tube migration. Checking breath sounds can confirm proper tube placement. A may not address the underlying issue. B could worsen the situation if the tube is misplaced. D is not urgent compared to assessing airway integrity.