Nokea
What factors may predispose a patient to respiratory acido as bi is rb? . com/test
- A. Anxiety and fear
- B. Central nervous system depression
- C. Diabetic ketoacidosis
- D. Nasogastric suctioning
Correct Answer: B
Rationale: The correct answer is B: Central nervous system depression. This factor can lead to respiratory acidosis by depressing the respiratory drive, causing hypoventilation and retention of carbon dioxide. Anxiety and fear (A) may lead to hyperventilation, reducing carbon dioxide levels. Diabetic ketoacidosis (C) results in metabolic acidosis, not respiratory acidosis. Nasogastric suctioning (D) may cause respiratory alkalosis from excessive removal of carbon dioxide. Thus, central nervous system depression is the most likely factor predisposing a patient to respiratory acidosis.
You may also like to solve these questions
The nurse recognizes that which patient is likely to benefit most from patient-controlled analgesia?
- A. 21-year-old with a C4 fracture and quadriplegia
- B. 45-year-old with femur fracture and closed head injury
- C. 59-year-old postoperative elective bariatric surgery
- D. 70-year-old postoperative cardiac surgery; mild demen tia
Correct Answer: A
Rationale: The correct answer is A, the 21-year-old with a C4 fracture and quadriplegia. This patient is likely to benefit most from patient-controlled analgesia (PCA) due to the inability to self-administer traditional pain medications. With quadriplegia, the patient may have limited mobility and sensation, making it challenging to communicate pain levels effectively. PCA allows the patient to control their pain relief within preset limits, enhancing autonomy and optimizing pain management.
Summary:
- Choice B: The 45-year-old with femur fracture and closed head injury may benefit from PCA, but the severity of the head injury could affect their ability to use the device effectively.
- Choice C: The 59-year-old postoperative elective bariatric surgery patient can typically manage pain with traditional methods postoperatively.
- Choice D: The 70-year-old postoperative cardiac surgery patient with mild dementia may have the cognitive ability to use PCA but could potentially benefit more from other pain management strategies due
A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?
- A. Heart rate.
- B. Breath sounds.
- C. Body temperature.
- D. Level of consciousness.
Correct Answer: C
Rationale: The correct answer is C: Body temperature. In a patient who has fallen through the ice, hypothermia is a major concern due to exposure to cold water. Assessing body temperature first is crucial to determine the severity of hypothermia and guide immediate interventions. Heart rate, breath sounds, and level of consciousness can be affected by hypothermia but are secondary assessments. Assessing body temperature is the priority to address the most life-threatening issue first.
Which treatment can be used to dissolve a thrombus that is lodged in the pulmonary artery?
- A. Aspirin
- B. Embolectomy
- C. Heparin
- D. Thrombolytics
Correct Answer: D
Rationale: The correct answer is D: Thrombolytics. Thrombolytics are medications that can dissolve blood clots, making them effective in treating a thrombus lodged in the pulmonary artery. They work by activating the body's natural clot-dissolving system. Aspirin (A) is an antiplatelet drug and may prevent further clot formation but cannot dissolve an existing thrombus. Embolectomy (B) is a surgical procedure to remove a clot and is invasive, usually reserved for cases where thrombolytics are contraindicated. Heparin (C) is an anticoagulant that prevents clot formation but does not dissolve existing clots like thrombolytics do.
Which patient should the nurse notify the organ procureme nt organization (OPO) to evaluate for possible organ donation?
- A. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram
- B. A 68-year-old male admitted with unstable atrial fibrillation who has suffered a stroke
- C. A 40-year-old brain-injured female with a history of ovabairrbi.acnom c/taenstc er and a Glasgow Coma Scale score of 7
- D. A 53-year-old diabetic male with a history of unstable angina status post resuscitation
Correct Answer: A
Rationale: The correct answer is A because the patient is a 36-year-old with a Glasgow Coma Scale score of 3 and no activity on electroencephalogram, indicating severe brain injury and likely irreversible neurological damage. This patient meets the criteria for potential organ donation as they are neurologically devastated.
Choice B is incorrect because the patient's condition is related to stroke and atrial fibrillation, not severe brain injury that would make them a candidate for organ donation.
Choice C is incorrect because although the patient has a brain injury and a lower Glasgow Coma Scale score, the history of a reversible cause (ovarian cancer metastasis) and a higher GCS score compared to choice A make this patient less suitable for organ donation evaluation.
Choice D is incorrect as the patient's diabetic and cardiovascular history does not suggest severe brain injury that would qualify for organ donation.
As part of nursing management of a critically ill patient, o rders are written to keep the head of the bed elevated at 30 degrees, awaken the patient from se dation each morning to assess readiness to wean from mechanical ventilation, and implement oral care protocols every 4 hours. These interventions are done as a group to reduce thabei rrbi.csokm o/tef svt entilator-associated pneumonia. This group of evidence-based interventions is often referred to using what term?
- A. Bundle of care.
- B. Clinical practice guideline.
- C. Patient safety goal.
- D. Quality improvement initiative.
Correct Answer: A
Rationale: The correct answer is A: Bundle of care. A bundle of care refers to a set of evidence-based interventions that, when implemented together, have been shown to improve patient outcomes. In this scenario, keeping the head of the bed elevated, daily awakening from sedation, and oral care protocols are bundled together to reduce the risk of ventilator-associated pneumonia. This approach is based on the idea that implementing multiple interventions simultaneously is more effective than individual interventions alone.
Choices B, C, and D are incorrect because:
B: Clinical practice guidelines provide recommendations for healthcare providers based on evidence but do not necessarily involve a group of interventions bundled together.
C: Patient safety goals are specific objectives aimed at improving patient safety outcomes, but they do not specifically refer to a group of interventions bundled together.
D: Quality improvement initiatives focus on improving processes and outcomes in healthcare settings but do not necessarily involve a group of interventions bundled together for a specific purpose like in this case.