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The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next?
- A. Activate the rapid response team.
- B. Provide reassurance to the patient.
- C. Call the health care provider to reinsert the tube.
- D. Manually ventilate the patient with 100% oxygen.
Correct Answer: D
Rationale: The correct action is D: Manually ventilate the patient with 100% oxygen. This is crucial to ensure adequate oxygenation and prevent hypoxia. Holding the ET tube can lead to extubation and airway compromise. Activating the rapid response team (A) may delay immediate intervention. Providing reassurance (B) is important but not the priority in this situation. Calling the health care provider (C) to reinsert the tube would also lead to a delay in providing essential respiratory support.
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The critical care nurse knows that in critically ill patients, renal dysfunction
- A. is a very rare problem.
- B. affects nearly two thirds of patients.
- C. has a low mortality rate once renal replacement therapy has been initiated.
- D. has little effect on morbidity, mortality, or quality of life.
Correct Answer: B
Rationale: The correct answer is B. Renal dysfunction is common in critically ill patients due to various factors like sepsis, hypotension, and nephrotoxic medications. This affects nearly two thirds of patients, making it a significant issue in critical care. Choices A, C, and D are incorrect. A is wrong because renal dysfunction is not rare in critically ill patients. C is incorrect as renal replacement therapy does not guarantee low mortality rates. D is inaccurate as renal dysfunction can have a significant impact on morbidity, mortality, and quality of life in critically ill patients.
Intrapulmonary shunting refers to what outcome?
- A. Alveoli that are not perfused.
- B. Blood that is shunted from the left side of the heart to t he right and causes heart failure.
- C. Blood that is shunted from the right side of the heart to the left without oxygenation.
- D. Shunting of blood supply to only one lung.
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Intrapulmonary shunting refers to blood bypassing the normal oxygenation process in the lungs.
2. Choice C describes blood being shunted from the right side of the heart (deoxygenated blood) to the left side without oxygenation, leading to systemic circulation without oxygenation.
3. Choices A, B, and D do not accurately describe intrapulmonary shunting as they focus on other concepts like alveolar perfusion, heart failure, and unilateral lung blood supply, respectively.
A nurse walks into a patients room and begins preparing a syringe to perform a blood draw on the patient. The nurse observes that the patient is firmly gripping the side of the bed, averting her eyes, and sweating from her forehead when she sees the needle. What would be the best intervention for the nurse to make?
- A. Proceed with blood draw as quickly as possible, to get it over with.
- B. Offer to come back later to perform the blood draw.
- C. Encourage the patient to deep breathe.
- D. Describe briefly the blood draw procedure and explain why it is necessary.
Correct Answer: D
Rationale: The correct answer is D because it shows empathy and promotes patient education. By describing the procedure and its necessity, the nurse can alleviate the patient's anxiety and build trust. This approach allows the patient to feel informed and in control, reducing fear and increasing cooperation. It also demonstrates respect for the patient's feelings and promotes a therapeutic relationship.
Choice A is incorrect as it disregards the patient's fear and can lead to increased distress. Choice B might be an option, but it doesn't address the patient's anxiety in the moment. Choice C, while helpful in some cases, doesn't directly address the patient's specific fear of the blood draw procedure.
A 22-year-old patient who experienced a near-drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?
- A. Auscultate heart sounds.
- B. Palpate peripheral pulses.
- C. Auscultate breath sounds.
- D. Check pupil reaction to light.
Correct Answer: C
Rationale: The correct answer is C: Auscultate breath sounds. After a near-drowning incident, the main concern is potential respiratory complications such as aspiration pneumonia or pulmonary edema. Auscultating breath sounds will help the nurse assess for any signs of respiratory distress or complications. This assessment is crucial for early detection and intervention.
A: Auscultating heart sounds is important but not as crucial as assessing breath sounds in this scenario.
B: Palpating peripheral pulses is important for circulation assessment but does not address the immediate concern of respiratory complications.
D: Checking pupil reaction to light is more relevant for neurological assessment and not as critical as assessing breathing in this situation.
A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT?
- A. New ST segment elevation is noted on the cardiac monitor.
- B. Enteral feedings are being given through an orogastric tube.
- C. Scattered rhonchi are heard when auscultating breath sounds.
- D. HYDROmorphone (Dilaudid) is being used to treat postoperative pain.
Correct Answer: A
Rationale: The correct answer is A: New ST segment elevation is noted on the cardiac monitor. This finding is concerning because it may indicate myocardial ischemia or infarction, which can be exacerbated by the physiological stress of weaning from mechanical ventilation. It is crucial to address any cardiac issues before initiating a spontaneous breathing trial to prevent potential cardiac complications during the weaning process.
Explanation for why the other choices are incorrect:
B: Enteral feedings being given through an orogastric tube are not contraindicated for starting a spontaneous breathing trial.
C: Scattered rhonchi heard when auscultating breath sounds may indicate retained secretions but are not a contraindication for a spontaneous breathing trial.
D: The use of HYDROmorphone to treat postoperative pain is not a contraindication for a spontaneous breathing trial unless it is causing respiratory depression, which would need to be addressed separately.