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The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the healthcare provider immediately if the patient develops:
- A. Oxygen saturation of 93%.
- B. Respirations of 20 breaths/minute.
- C. Green nasogastric tube drainage.
- D. Increased jugular venous distention.
Correct Answer: D
Rationale: The correct answer is D: Increased jugular venous distention. In a patient with a subarachnoid hemorrhage and on mechanical ventilation, increased jugular venous distention can indicate increased intracranial pressure, which can be life-threatening. The nurse should notify the healthcare provider immediately as it may require urgent intervention to prevent further neurological deterioration.
A: Oxygen saturation of 93% is within the acceptable range for a patient on mechanical ventilation and may not require immediate notification.
B: Respirations of 20 breaths/minute are within normal limits for a ventilated patient and do not necessarily indicate a critical condition.
C: Green nasogastric tube drainage may indicate the presence of bile and could be related to gastrointestinal issues, but it does not pose an immediate threat to the patient's neurological status.
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The nurse cares for a patient with lung cancer in a home hospice program. Which action by the nurse is most appropriate?
- A. Discuss cancer risk factors and appropriate lifestyle modifications.
- B. Encourage the patient to discuss past life events and their meaning.
- C. Teach the patient about the purpose of chemotherapy and radiation.
- D. Accomplish a thorough head-to-toe assessment several times a week.
Correct Answer: B
Rationale: The correct answer is B because in a home hospice program, it is essential for the nurse to provide holistic care that includes addressing the patient's emotional and psychological needs. Encouraging the patient to discuss past life events and their meaning can help them process emotions, find closure, and improve their quality of life. This approach aligns with the principles of palliative care, which focus on enhancing comfort and well-being.
Choice A is incorrect because discussing cancer risk factors and lifestyle modifications may not be relevant or beneficial for a patient in a hospice program. Choice C is incorrect because chemotherapy and radiation are typically not part of hospice care, which focuses on comfort rather than curative treatments. Choice D is incorrect because a thorough head-to-toe assessment multiple times a week may not be necessary or appropriate for a patient in a hospice program.
A nurse is on a committee that is trying to reduce the occurrence of hospital-acquired infections in the ICU. Her role is to conduct research to find which interventions have been shown to be most effective in reducing these infections. She consults many different sources and finds conflicting information. Which of the following sources should she consider the most authoritative?
- A. AACN expert panel report
- B. A meta-analysis of randomized controlled trials in the American Journal of Nursing
- C. A systematic review of qualitative studies in the Journal of Advanced Nursing
- D. A single randomized controlled trial in the American Journal of Critical Care
Correct Answer: B
Rationale: The correct answer is B: A meta-analysis of randomized controlled trials in the American Journal of Nursing.
1. Meta-analyses provide a comprehensive overview of multiple studies, increasing the reliability of the findings.
2. Randomized controlled trials are considered the gold standard in research design for assessing intervention effectiveness.
3. The American Journal of Nursing is a reputable source in the field of nursing, ensuring the credibility of the study.
4. By synthesizing data from various trials, the meta-analysis can offer a more robust and generalizable conclusion compared to a single trial or qualitative studies.
Incorrect choices:
A: AACN expert panel report - Expert opinions may vary and lack the empirical evidence provided by research studies.
C: A systematic review of qualitative studies in the Journal of Advanced Nursing - Qualitative studies may provide valuable insights but may not offer concrete evidence on intervention effectiveness like quantitative studies.
D: A single randomized controlled trial in the American Journal of Critical Care - Single trials may not capture the full picture and
A 65-year-old patient with a history of metastatic lung car cinoma has been unresponsive to chemotherapy. The medical team has determined that ther e are no additional treatments available that will prolong life or improve the quality of lifaebi ribn.c oamn/yte smt eaningful way. Despite the poor prognosis, the patient continues to receive chemotherapy and full nutrition support. This is an example of what end-of-life concept?
- A. Medical futility
- B. Palliative care
- C. Terminal weaning
- D. Withdrawal of treatment
Correct Answer: A
Rationale: The correct answer is A: Medical futility. In this scenario, the patient's condition is terminal with no treatment options left. Continuing chemotherapy offers no benefit and may even harm the patient. Medical futility refers to interventions that are unlikely to achieve the desired outcome.
B: Palliative care focuses on improving quality of life for patients with serious illnesses, which is not being addressed in this case.
C: Terminal weaning involves gradually removing life-support measures, which is not happening here.
D: Withdrawal of treatment would be appropriate if the treatments were no longer beneficial, but the issue here is the continued provision of futile treatment.
A patient nearing death experiences increased secretions and noisy breathing. What is the nurse’s priority intervention?
- A. Provide suctioning every hour.
- B. Administer anticholinergic medications as prescribed.
- C. Elevate the head of the bed and reposition frequently.
- D. Restrict oral intake to minimize secretions.
Correct Answer: B
Rationale: The correct answer is B: Administer anticholinergic medications as prescribed. Anticholinergic medications can help dry up secretions and improve breathing in a patient nearing death. This intervention targets the underlying cause of increased secretions. Suctioning (choice A) may provide temporary relief but does not address the root issue. Elevating the head of the bed and repositioning (choice C) can help with comfort but do not directly address the secretions. Restricting oral intake (choice D) may lead to dehydration and discomfort without effectively managing the secretions. Administering anticholinergic medications is the priority as it directly targets the symptom of increased secretions, improving the patient's comfort and quality of life.
To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should:
- A. Inflate the cuff with a minimum of 10 mL of air.
- B. Inflate the cuff until the pilot balloon is firm on palpation.
- C. Inject air into the cuff until a manometer shows 15 mm Hg pressure.
- D. Inject air into the cuff until a slight leak is heard only at peak inflation.
Correct Answer: D
Rationale: The correct answer is D because inflating the cuff until a slight leak is heard only at peak inflation ensures it is adequately sealed but not overinflated, preventing complications like tracheal injury or pressure necrosis. Choice A lacks specificity and can lead to overinflation. Choice B may result in overinflation as the firmness of the balloon is subjective. Choice C relies on a specific pressure reading, which may vary based on factors like tube size and patient anatomy, potentially leading to under- or overinflation.