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A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam 1 to 2 mg IV as needed (prn). The patient has received no lorazepam during this course of illness. What is the most appropriate nursing intearbvirbe.ncotmio/tnes tt o control agitation?
- A. Administer fentanyl (Duragesic) 25 mg IV bolus.
- B. Administer midazolam 2 mg IV now.
- C. Increase the rate of the morphine infusion by 50%.
- D. Request an order for a paralytic agent.
Correct Answer: B
Rationale: Step-by-step rationale for why choice B is correct:
1. Midazolam is a benzodiazepine used for sedation and anxiolysis.
2. It acts quickly and has a short duration of action, suitable for acute agitation.
3. Lorazepam (also a benzodiazepine) is in the same drug class, ensuring compatibility.
4. Lorazepam is specifically ordered for this patient, indicating its appropriateness.
5. Administering midazolam addresses the patient's agitation efficiently and safely.
Summary of why other choices are incorrect:
A: Fentanyl is an opioid analgesic, not ideal for managing agitation.
C: Increasing morphine infusion can exacerbate sedation or respiratory depression.
D: Paralytic agents are used for neuromuscular blockade, not agitation control.
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A 65-year-old patient admitted to the progressive care unit with a diagnosis of community-acquired pneumonia, has a history of chronic obstructive pulmonary disease and diabetes. A set of arterial blood gases obtained on admissiaobnir bw.coitmh/oteustt supplemental oxygen shows pH 7.35; PaCO 55 mm Hg; bicarbonate 30 mEq/L ; PaO 65 mm Hg. These blood 2 2 gases reflect what condition?
- A. Hypoxemia and compensated metabolic alkalosis.
- B. Hypoxemia and compensated respiratory acidosis.
- C. Normal oxygenation and partly compensated metaboli c alkalosis.
- D. Normal oxygenation and uncompensated respiratory acidosis.
Correct Answer: B
Rationale: The correct answer is B: Hypoxemia and compensated respiratory acidosis. The patient's pH is within normal range (7.35), indicating compensation. The elevated PaCO2 (55 mm Hg) indicates respiratory acidosis due to inadequate ventilation, likely from COPD. The low PaO2 (65 mm Hg) indicates hypoxemia, common in pneumonia. The normal bicarbonate level (30 mEq/L) suggests metabolic compensation for respiratory acidosis. Choice A is incorrect as there is no metabolic alkalosis present. Choice C is incorrect as the patient has hypoxemia. Choice D is incorrect as the patient is showing compensated respiratory acidosis, not uncompensated.
Which statement made by a staff nurse identifying guidelianbeirsb .fcoomr /pteaslt liative care would need corrected?
- A. Basic nursing care is a critical element in palliative car e management.
- B. Common conditions that require palliative management are nausea, agitation, and sleep disturbance.
- C. Palliative care practices are reserved for the dying clie nt.
- D. Palliative care practices relieve symptoms that negativ ely affect the quality of life of a patient.
Correct Answer: C
Rationale: The correct answer is C because palliative care is not just for the dying but also for those with serious illnesses. A: Correct - basic nursing care is essential in palliative care. B: Correct - common symptoms in palliative care include nausea, agitation, and sleep disturbance. D: Correct - palliative care aims to relieve symptoms and improve quality of life. Choice C is incorrect as it wrongly implies palliative care is only for the dying, which is a misconception.
Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict?
- A. Require the UAPs to reach a compromise.
- B. Weigh the consequences of each possible solution.
- C. Encourage the two to view the humor of the conflict.
- D. Deal with issues and not personalities.
Correct Answer: D
Rationale: The correct answer is D: Deal with issues and not personalities. This guideline is important because it focuses on resolving the conflict based on the actual problem at hand, rather than personal biases or emotions. By addressing the issues causing the argument, the nurse can help the UAPs find a fair and logical solution.
A: Requiring the UAPs to reach a compromise may not address the root cause of the conflict and could lead to further disagreements.
B: Weighing the consequences is important but may not be as effective in resolving the conflict as directly addressing the issues.
C: Encouraging humor may temporarily diffuse the situation but may not lead to a lasting resolution.
When assessing the patient for hypoxemia, the nurse recognizes what as an early sign of the effect of hypoxemia on the cardiovascular system?
- A. Heart block
- B. Restlessness
- C. Tachycardia
- D. Tachypnea
Correct Answer: C
Rationale: The correct answer is C: Tachycardia. Hypoxemia results in decreased oxygen levels in the blood, stimulating the body to increase heart rate to improve oxygen delivery. Tachycardia is an early sign of the cardiovascular system compensating for hypoxemia. Heart block (A) is a disruption in the electrical conduction within the heart and is not directly related to hypoxemia. Restlessness (B) is a non-specific sign and can be caused by various factors. Tachypnea (D) is an increased respiratory rate, which is a response to hypoxemia but not a direct effect on the cardiovascular system.
The nurse is caring for a mechanically ventilated patient an d is charting outside the patient’s room when the ventilator alarm sounds. What is the priorit y order for the nurse to complete these actions? (Put a comma and space between each answer choice.)
- A. Check quickly for possible causes of the alarm that can be fixed.
- B. After troubleshooting, connect back to mechanical venti lator and reassess patient.
- C. Go to patient’s bedside.
- D. Manually ventilate the patient while getting respiratory therapist.
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Going to the patient’s bedside is the priority as it allows the nurse to assess the patient's condition directly.
2. By being at the bedside, the nurse can quickly evaluate the patient's breathing, vital signs, and other indicators for immediate action.
3. Direct assessment enables timely intervention and avoids delays in addressing potential life-threatening situations.
4. Checking for possible causes of the alarm and reconnection to the ventilator can follow, but assessing the patient's immediate needs takes precedence.
In summary, choice C is correct because direct patient assessment is the fundamental step in responding to a ventilator alarm to ensure patient safety and timely intervention. Choices A, B, and D are incorrect as they focus on troubleshooting and technical aspects before directly assessing the patient's condition.