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The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues?
- A. Arterial lactate level of 1.0 mEq/L
- B. Cardiac output of 2.5 L/min
- C. Mixed venous (SvO ) of 40%
- D. Cardiac index of 1.5 L/min/m2
Correct Answer: C
Rationale: The correct answer is C: Mixed venous (SvO2) of 40%. In septic shock, improving oxygen delivery to tissues is vital. SvO2 reflects the balance between oxygen delivery and consumption. A value of 40% indicates adequate oxygen delivery to tissues.
A: Arterial lactate level of 1.0 mEq/L - Although a low lactate level is good, it does not directly indicate improved oxygen delivery.
B: Cardiac output of 2.5 L/min - Cardiac output should ideally increase to improve oxygen delivery, so 2.5 L/min is low for a 70-kg patient.
D: Cardiac index of 1.5 L/min/m2 - Cardiac index is cardiac output adjusted for body surface area. 1.5 L/min/m2 is low and indicates inadequate cardiac function for a patient in septic shock.
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An 80-year-old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client?
- A. Antacids.
- B. Tricyclic antidepressants.
- C. Nonsteroidal anti-inflammatory agents.
- D. Insulin.
Correct Answer: B
Rationale: The correct answer is B: Tricyclic antidepressants. Tricyclic antidepressants can cause anticholinergic effects, including urinary retention, especially in the elderly. Morphine sulfate can also contribute to urinary retention. Antacids (A) and nonsteroidal anti-inflammatory agents (C) are not known to cause urinary retention. Insulin (D) does not pose a risk for urinary retention in this scenario.
Which acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: The correct answer is D: Respiratory alkalosis. Hyperventilation in severe asthma exacerbation leads to excessive removal of CO2, causing a decrease in carbonic acid levels, resulting in respiratory alkalosis. Metabolic acidosis (A) is not typically associated with hyperventilation. Metabolic alkalosis (B) is caused by excessive loss of acid or gain of bicarbonate, not by hyperventilation. Respiratory acidosis (C) is characterized by an increase in CO2 levels due to inadequate ventilation, which is the opposite of what occurs in severe asthma exacerbation.
When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)?
- A. Assist with endotracheal intubation.
- B. Insert an indwelling urinary catheter.
- C. Begin continuous cardiac monitoring.
- D. Obtain an order to restrain the patient.
Correct Answer: C
Rationale: Rationale:
Continuous cardiac monitoring is crucial during therapeutic hypothermia to monitor the patient's cardiac rhythm and detect any arrhythmias promptly. This intervention allows for immediate intervention if any cardiac issues arise.
Explanation of other choices:
A: Assisting with endotracheal intubation may be necessary for airway management but is not directly related to cooling the patient for therapeutic hypothermia.
B: Inserting an indwelling urinary catheter may be needed for urine output monitoring but is not a priority intervention for cooling the patient.
D: Restraining the patient is unnecessary and not indicated for therapeutic hypothermia; it may cause unnecessary distress and should be avoided unless absolutely necessary for patient safety.
Which of the following nursing activities demonstrates im plementation of the AACN Standards of Professional Performance? (Select all that ap ply.)
- A. Attending a meeting of the local chapter of the Americ an Association of Critical-Care Nurses in which a continuing education program on sepsis is being taught
- B. Collaborating with a pastoral services colleague to assist in meeting spiritual needs of the patient and family
- C. Participating on the unit’s nurse practice council
- D. Posting an article from Critical Care Nurse on manage ment of venous thromboembolism for your colleagues to read
Correct Answer: C
Rationale: The correct answer is C because participating on the unit's nurse practice council demonstrates adherence to the AACN Standards of Professional Performance, specifically the standard related to quality of practice. By actively engaging in the nurse practice council, the nurse contributes to the development and implementation of policies and procedures that promote quality patient care. This activity also involves collaboration, leadership, and advocacy, which are essential components of professional nursing practice.
The other choices are incorrect because:
A: Attending a meeting and receiving continuing education on sepsis is important for professional development but does not directly align with the AACN Standards of Professional Performance.
B: Collaborating with a pastoral services colleague is essential for holistic patient care but does not specifically address the standards set by the AACN.
D: Posting an article for colleagues to read is beneficial for knowledge sharing but does not directly demonstrate adherence to the AACN Standards of Professional Performance.
A family member tells the nurse, 'I don’t know how I’m going to manage without my mother. She took care of everything for us.' Which response by the nurse is most appropriate?
- A. You will learn how to manage things gradually, and I can provide some resources to help you.
- B. It will be difficult at first, but time will help you adjust to her loss.
- C. Perhaps another family member can take over the responsibilities your mother managed.
- D. It sounds like you will need to seek professional counseling to cope with this loss.
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the family member's feelings while offering support and resources for managing the situation gradually. By providing resources, the nurse empowers the family member to learn how to handle things independently over time. This approach promotes self-reliance and resilience.
Choice B focuses on time rather than active coping strategies, which may not address the family member's immediate needs. Choice C suggests shifting responsibilities to another family member without considering the emotional impact. Choice D jumps to the conclusion of needing professional counseling without exploring other potential solutions or support systems.