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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.
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The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 12 5 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO ) of 90% on a 50% venturi mask. 2 Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pres sure (PAOP) of 3 mm Hg. The nurse questions which of the following primary health care provider’s order?
- A. Titrate supplemental oxygen to achieve a SpO > 94%a. birb.com/test
- B. Infuse 500 mL 0.9% normal saline over 1 hour.
- C. Obtain arterial blood gas and serum electrolytes.
- D. Administer furosemide 20 mg intravenously.
Correct Answer: D
Rationale: The correct answer is D: Administer furosemide 20 mg intravenously. In this scenario, the patient is hypotensive with a low cardiac output, low CVP, and low PAOP, indicating cardiogenic shock. Administering furosemide, a diuretic, can worsen the patient's condition by further decreasing preload. This can lead to a decrease in cardiac output and exacerbate the shock state. The other options are more appropriate:
A: Titrate supplemental oxygen to achieve a SpO > 94% - Correct, as improving oxygenation is essential in cardiogenic shock.
B: Infuse 500 mL 0.9% normal saline over 1 hour - Correct, as fluid resuscitation may be necessary to improve perfusion.
C: Obtain arterial blood gas and serum electrolytes - Correct, as these tests provide valuable information about the patient's oxygenation and electrolyte balance.
Continuous venovenous hemodialysis is used to
- A. remove fluids and solutes through the process of convection.
- B. remove plasma water in cases of volume overload.
- C. remove plasma water and solutes by adding dialysate.
- D. combine ultrafiltration, convection and dialysis
Correct Answer: D
Rationale: The correct answer is D because continuous venovenous hemodialysis combines ultrafiltration, convection, and dialysis techniques. Ultrafiltration removes excess fluid, convection helps in removing solutes, and dialysis involves the diffusion of solutes across a semipermeable membrane. This comprehensive approach ensures effective removal of both fluid and solutes in critically ill patients.
Incorrect Answer Analysis:
A: Removing fluids and solutes through convection alone is not the complete process in continuous venovenous hemodialysis.
B: While volume overload is addressed, continuous venovenous hemodialysis involves more than just removing plasma water.
C: Adding dialysate is not the primary method in continuous venovenous hemodialysis; it involves ultrafiltration, convection, and dialysis techniques.
The nurse has identified an increase in medication errors in the critical care unit over the past several months. What aspect of medication procedures should be evaluated first?
- A. Adherence to procedures by nursing staff
- B. Clarity of interdisciplinary communication
- C. Number of new employees on the unit
- D. Changes in administration procedures
Correct Answer: A
Rationale: The correct answer is A: Adherence to procedures by nursing staff. This should be evaluated first because medication errors are often caused by human factors such as staff not following proper procedures. By assessing adherence, the root cause of errors can be identified and addressed.
Choice B: Clarity of interdisciplinary communication may contribute to errors but doesn't directly address staff adherence to procedures.
Choice C: Number of new employees could be a factor, but focusing on adherence to procedures is more crucial.
Choice D: Changes in administration procedures may impact errors, but evaluating staff adherence is more immediate and directly related to errors.
The nurse is educating a patient’s family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates undaebrisrbt.acnomd/itnesgt of the purpose of the PAC?
- A. “The catheter will provide multiple sites to give intravenous fluid.”
- B. “The catheter will allow the primary health care provid er to better manage fluid therapy.”
- C. “The catheter tip comes to rest inside my brother’s pul monary artery.”
- D. “The catheter will be in position until the heart has a chance to heal.”
Correct Answer: B
Rationale: The correct answer is B because it shows understanding that the PAC helps in managing fluid therapy effectively. The PAC measures pressures in the heart and lungs, guiding fluid management. Choice A is incorrect as the PAC is not primarily for IV fluid administration. Choice C shows understanding of the catheter placement but not its purpose. Choice D is incorrect as the PAC is not for the heart to heal but to monitor cardiac status.
What must the patient must be able of in order to provide informed consent?
- A. Be capable of independent breathing.
- B. Have knowledge and competence to make the decision .
- C. Nod head to agree to the procedure.
- D. Both read and write in English.
Correct Answer: B
Rationale: The correct answer is B because informed consent requires the patient to have knowledge and competence to make a decision. This involves understanding the risks, benefits, and alternatives of the proposed treatment. Choice A is incorrect as it pertains to a physical ability unrelated to decision-making. Choice C is incorrect as consent must be verbal or written, not just nodding. Choice D is incorrect as consent can be obtained in various ways, not specifically through reading and writing in English.