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The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT). In doing so, the nurse should
- A. assess that the blood tubing is warm to the touch.
- B. assess the hemofilter every 6 hours for clotting.
- C. cover the dialysis lines to protect them from light.
- D. use clean technique during vascular access dressing changes.
Correct Answer: B
Rationale: The correct answer is B because assessing the hemofilter every 6 hours for clotting is essential in ensuring the effectiveness of CRRT. Clotting can obstruct blood flow, leading to treatment inefficiency and potential harm to the patient. This step helps the nurse to promptly address any clotting issues and prevent complications.
A: Assessing that the blood tubing is warm to the touch is not a standard practice for monitoring CRRT and does not provide relevant information about the treatment's effectiveness.
C: Covering the dialysis lines to protect them from light is not a priority in monitoring CRRT. Light exposure is not a common concern in this context.
D: Using clean technique during vascular access dressing changes is important for infection prevention but is not directly related to monitoring the effectiveness of CRRT.
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The nurse observes that an elderly woman, whose granddaughter has been admitted to theICU, is struggling to manage her two great-grandsons, who are toddlers, in the waiting room. What is the most likely explanation for the womans inability to manage the children in this situation?
- A. She is senile.
- B. She is in the exhaustion stage of the general adaptation syndrome to stress.
- C. She is assuming the role of caregiver in place of the patient, a role she is not used to.
- D. She has macular degeneration and cannot see well.
Correct Answer: B
Rationale: The correct answer is B: She is in the exhaustion stage of the general adaptation syndrome to stress.
Rationale:
1. In the exhaustion stage, the body's resources are depleted due to prolonged stress, leading to fatigue and reduced ability to cope.
2. The elderly woman is likely experiencing high levels of stress due to her granddaughter's critical condition.
3. Managing toddlers while dealing with the emotional distress of a loved one in the ICU can be overwhelming, causing exhaustion.
4. This explanation aligns with the symptoms of fatigue and difficulty managing the children observed by the nurse.
Summary:
A: Incorrect. Senility is a cognitive condition unrelated to the stress of the situation.
C: Incorrect. Assuming a caregiver role can be stressful, but it does not explain the observed exhaustion.
D: Incorrect. Macular degeneration affects vision, not the ability to manage stress and children.
Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first?
- A. Insert a large-bore orogastric tube.
- B. Assist with the intubation of the patient.
- C. Prepare a 60-mL syringe with saline.
- D. Give the first dose of activated charcoal.
Correct Answer: B
Rationale: The correct answer is B: Assist with the intubation of the patient. In this scenario, the patient is unconscious and has ingested a potentially harmful substance. Intubation is the first priority to maintain the patient's airway and ensure adequate oxygenation. This step is crucial in preventing aspiration of gastric contents and securing the patient's respiratory status. Inserting a large-bore orogastric tube (choice A) is not the priority as airway management takes precedence. Preparing a syringe with saline (choice C) is unnecessary at this stage. Giving the first dose of activated charcoal (choice D) should only be done after securing the airway to prevent aspiration.
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should:
- A. Obtain a complete set of vital signs.
- B. Obtain a Glasgow Coma Scale score.
- C. Ask about chronic medical conditions.
- D. Attach a cardiac electrocardiogram monitor.
Correct Answer: B
Rationale: The correct answer is B: Obtain a Glasgow Coma Scale score. During the primary survey, assessing the patient's level of consciousness is crucial as it helps determine the severity of the injury and guides further management. The Glasgow Coma Scale is a standardized tool used to assess the level of consciousness based on eye opening, verbal response, and motor response. It provides valuable information about the patient's neurological status.
A: Obtaining a complete set of vital signs is important but assessing the level of consciousness takes priority in this scenario.
C: Asking about chronic medical conditions is important but not as critical as assessing the patient's level of consciousness during the primary survey.
D: Attaching a cardiac electrocardiogram monitor is not necessary during the primary survey unless there are specific indications of cardiac issues, which are not evident in this case.
In summary, obtaining a Glasgow Coma Scale score is essential for assessing the patient's level of consciousness and determining the severity of the injury during the primary survey.
A nurse in a burn unit observes that a patient is tensed up and frowning but silent. The nurse asks the patient, Can you tell me what you are thinking now? The patient responds, I cant take this pain any more! I feel like Im about to die. What would be the best response for the nurse to give to the patient, considering that the patient is already receiving the maximum amount pain medication that is safe?
- A. Try to get rid of those negative thoughtsthey only make it worse.
- B. Try thinking instead, This pain will go away; I can overcome it.
- C. Your pain medication is already at the highest possible dose.
- D. Would you like me to raise the head of your bed?
Correct Answer: C
Rationale: The correct response is C: Your pain medication is already at the highest possible dose. This response acknowledges the patient's pain and reassures them that they are already receiving the maximum safe amount of pain medication. By stating this, the nurse is validating the patient's experience and showing empathy. It is important for the nurse to communicate clearly about the medication to manage the patient's expectations.
Choice A is incorrect as it dismisses the patient's pain and can come across as insensitive. Choice B may be well-intentioned but does not address the immediate concern of the patient's pain. Choice D is irrelevant to the patient's statement about pain and does not offer any immediate support or reassurance regarding the pain management.
A patient is admitted to the hospital with multiple trauma aabnirdb .ceoxmte/tensst ive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vas cular resistance of 3000 dynes/sec/cm5, and a hematocrit of 20%. The nurse anticip ates administration of which the following therapies or medications?
- A. Blood transfusion
- B. Furosemide
- C. Dobutamine infusion
- D. Dopamine hydrochloride infusion
Correct Answer: C
Rationale: The correct answer is C: Dobutamine infusion. In this scenario, the patient is experiencing hypovolemic shock due to significant blood loss, resulting in low blood pressure, tachycardia, and low cardiac output. Dobutamine is a positive inotropic agent that increases cardiac contractility and output, helping to improve tissue perfusion.
Blood transfusion (A) is a common intervention for hypovolemic shock, but in this case, the patient's hematocrit is low, indicating dilutional anemia rather than acute blood loss, so addressing the cardiac output is more urgent. Furosemide (B) is a diuretic that would exacerbate the hypovolemia and worsen the patient's condition. Dopamine (D) is a vasopressor that primarily increases blood pressure, but in this case, the patient's low cardiac output is the main concern, making dobutamine a more appropriate choice.