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The multilumen pulmonary artery catheter allows the nurse to measure hemodynamic pressures at different points in the heart. When the tip enters the small branches of the pulmonary artery, the nurse can assess all of the following except:
- A. Central venous pressure (CVP)
- B. Pulmonary artery capillary pressure (PACP)
- C. Pulmonary artery obstructive pressure (PACP)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Rationale: The multilumen pulmonary artery catheter, when positioned in the small branches of the pulmonary artery, allows the nurse to measure various hemodynamic pressures. Central venous pressure (CVP), Pulmonary artery capillary pressure (PACP), and Pulmonary artery wedge pressure (PAWP) can be measured accurately at this point. However, "Pulmonary artery obstructive pressure" is not a valid or recognized hemodynamic pressure parameter. Instead, the correct term for this measurement that can be assessed using the catheter is the Pulmonary artery occlusion pressure (PAOP) or Pulmonary artery wedge pressure (PAWP), which reflects the left atrial pressure.
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Nursing interventions for a patient with a diagnosis of hyponatremia includes all of the following except:
- A. Assessing for symptoms of nausea and malaise
- B. Encouraging the intake of low-sodium liquids, such as coffee or tea
- C. Monitoring neurological status
- D. Restricting tap water intake
Correct Answer: B
Rationale: Hyponatremia is a condition characterized by low levels of sodium in the blood. Encouraging the intake of low-sodium liquids, such as coffee or tea, can further dilute the sodium levels in the body and worsen the condition. Instead, it is important to restrict fluid intake and focus on providing appropriate electrolyte replacement. Monitoring the patient's neurological status is crucial as severe hyponatremia can lead to neurological symptoms such as confusion, seizures, and coma. Assessing for symptoms like nausea and malaise helps in understanding the patient's condition. Restricting tap water intake is also necessary to help manage hyponatremia by preventing further dilution of sodium levels.
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
- A. Wait for the patient to complete the sentence.
- B. Immediately begin showing the patient various objects In the environment.
- C. Leave the room and come back later.
- D. Begin naming various objects that the patient could be referring to.
Correct Answer: A
Rationale: It is crucial to give the patient with aphasia time to complete their sentence. Aphasia can impact a person's ability to find the right words, so allowing them the time to express themselves can be helpful. Rushing or providing excessive cues could lead to frustration and may not allow the patient the opportunity to find the appropriate words on their own. Being patient and giving the individual time to communicate can be empowering and supportive.
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should highest priority to which intervention?
- A. Serving small portions bland food
- B. Encouraging rhythmic breathing exercises
- C. Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed
- D. Withholding fluids for the first 4 to 6 hours after chemotherapy administration
Correct Answer: C
Rationale: Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed should be the highest priority intervention for a client experiencing nausea and vomiting after cancer chemotherapy. Metoclopramide is a commonly used antiemetic medication that helps to reduce nausea and vomiting by enhancing gastric emptying and decreasing nausea. Dexamethasone, a corticosteroid, can also help alleviate inflammation that may contribute to the nausea and vomiting. By administering these medications as prescribed, the nurse can effectively address the client's symptoms and improve their comfort level. The other options, such as serving small portions bland food, encouraging rhythmic breathing exercises, and withholding fluids, are important interventions but should not take precedence over providing the prescribed antiemetic medications to manage the client's post-chemotherapy symptoms.
Which of the following respiratory conditions is always considered a medical emergency?
- A. Asthma
- B. Cystic fibrosis (CF)
- C. Epiglottiditis
- D. Laryngotracheobronchitis (LTB)
Correct Answer: C
Rationale: Epiglottiditis is always considered a medical emergency due to the potential risk of airway obstruction. The epiglottis is a flap of tissue that prevents food and liquids from entering the airway during swallowing. If the epiglottis becomes inflamed or infected, it can swell and block the airway, making it difficult or impossible for the person to breathe. This obstruction can rapidly progress to a life-threatening situation if not treated promptly. Therefore, epiglottiditis requires immediate medical attention to ensure the airway remains open and the individual can breathe properly.
The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which statement by the adolescent would indicate a need for further teaching?
- A. "I should avoid tub baths but may shower."
- B. "I have to stay on strict bed rest for 3 days."
- C. "I should remove the pressure dressing the day after the procedure."
- D. "I may attend school but should avoid exercise for several days."
Correct Answer: B
Rationale: The statement "I have to stay on strict bed rest for 3 days" would indicate a need for further teaching. After a cardiac catheterization, strict bed rest is usually not required for an extended period of time. The patient is typically advised to limit physical activities for a certain period but can engage in light activities as tolerated. Prolonged bed rest can increase the risk of complications such as blood clots and muscle weakness. It would be important to clarify this misconception and provide accurate information regarding post-procedure care.