Nokea
Which action is a priority for the nurse to take when the low-pressure alarm sounds for a patient who has an arterial line in the left radial artery?
- A. Fast flush of the arterial line.
- B. Check the left hand for pallor.
- C. Assess for cardiac dysrhythmias.
- D. Rezero the monitoring equipment.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): When the low-pressure alarm sounds for a patient with an arterial line, the nurse should assess for cardiac dysrhythmias first. This is because a sudden drop in pressure could indicate a serious issue affecting the heart's ability to pump effectively. Identifying and addressing any cardiac dysrhythmias promptly is crucial for patient safety.
Summary of Incorrect Choices:
A: Fast flush of the arterial line - This would not address the underlying cause of the low-pressure alarm and may not be necessary.
B: Check the left hand for pallor - While assessing perfusion is important, it is not the priority when the alarm indicates a potential cardiac issue.
D: Rezero the monitoring equipment - While important for accuracy, it is not the priority when the alarm indicates a potential cardiac concern.
You may also like to solve these questions
The nurse is caring for four patients on the progressive car e unit. Which patient is at greatest risk for developing delirium?
- A. 36-year-old recovering from a motor vehicle crash with an alcohol withdrawal protocol.
- B. 54-year-old postoperative aortic aneurysm resection with an elevated creatinine level
- C. 86-year-old from nursing home, postoperative from coalboirnb .croemse/tecstti on
- D. 95-year-old with community-acquired pneumonia; fam ily has brought in eyeglasses and hearing aid
Correct Answer: C
Rationale: The correct answer is C, the 86-year-old postoperative from colonic resection. This patient is at the greatest risk for delirium due to being elderly, having undergone surgery, and having a history of being from a nursing home. These factors contribute to an increased susceptibility to delirium.
A: The 36-year-old with alcohol withdrawal may be at risk for delirium tremens, but the older age of the patient in choice C places them at higher risk.
B: The 54-year-old with an elevated creatinine level postoperative is at risk for complications, but age and history of nursing home placement increase the risk for delirium in choice C.
D: The 95-year-old with community-acquired pneumonia is at risk for delirium, but the combination of age, surgery, and nursing home history in choice C presents a greater risk.
Identify which substances in the glomerular filtrate would indicate a problem with renal function. (Select all that apply.)
- A. Protein
- B. Sodium
- C. Creatinine
- D. Red blood cells
Correct Answer: A
Rationale: The presence of protein in the glomerular filtrate indicates a problem with renal function because in healthy kidneys, proteins are retained in the blood and not filtered into the urine. If protein is found in the filtrate, it suggests damage to the glomerular filtration barrier. Sodium, creatinine, and red blood cells are normally present in the filtrate and are not indicative of renal dysfunction. Sodium is freely filtered and reabsorbed, creatinine is a waste product of muscle metabolism excreted by the kidneys, and a small number of red blood cells may be filtered due to their small size. Therefore, protein in the glomerular filtrate is the most specific indicator of renal dysfunction.
The nurse is caring for a patient who has an intra-aortic balloon pump in place. Which action should be included in the plan of care?
- A. Position the patient supine at all times.
- B. Avoid the use of anticoagulant medications.
- C. Measure the patient’s urinary output every hour.
- D. Provide a massive range of motion for all extremities.
Correct Answer: C
Rationale: The correct answer is C: Measure the patient’s urinary output every hour. This is crucial because monitoring urinary output is essential in assessing the patient’s renal function and the effectiveness of the intra-aortic balloon pump in improving cardiac output. Hourly measurement helps in early detection of any changes that may indicate complications.
A: Positioning the patient supine at all times is not necessary and can lead to complications.
B: Avoiding the use of anticoagulant medications is not appropriate as they are often necessary to prevent clot formation around the balloon pump.
D: Providing a massive range of motion for all extremities is not recommended for a patient with an intra-aortic balloon pump as it can dislodge the device or cause harm.
Which is the most important outcome for a patient receiving palliative care?
- A. Complete resolution of the underlying disease.
- B. Improvement in symptoms and quality of life.
- C. Increased adherence to curative treatments.
- D. Achievement of long-term survival goals.
Correct Answer: B
Rationale: The correct answer is B: Improvement in symptoms and quality of life. In palliative care, the primary focus is on enhancing the patient's quality of life by managing symptoms and providing comfort. This is achieved through effective symptom control, psychosocial support, and improving overall well-being. Complete resolution of the underlying disease (A) is often not possible in palliative care as the focus shifts from curative treatments to comfort care. Increased adherence to curative treatments (C) may not be the main goal in palliative care, as the emphasis is on improving the patient's comfort rather than prolonging life. Achievement of long-term survival goals (D) is not typically the primary outcome in palliative care, as the focus is on providing support and care for patients with life-limiting illnesses.
What are the diagnostic criteria for acute respiratory distress syndrome (ARDS)? (Select all that apply.)
- A. Bilateral infiltrates on chest x-ray study
- B. Decreased cardiac output
- C. PaO /FiO ratio of less than 200 2 2
- D. Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg
Correct Answer: A
Rationale: The correct answer is A: Bilateral infiltrates on chest x-ray study. ARDS diagnosis requires bilateral infiltrates on chest x-ray, indicative of non-cardiogenic pulmonary edema. Choice B, decreased cardiac output, is not a diagnostic criterion for ARDS. Choice C, PaO2/FiO2 ratio of less than 200, is a key diagnostic criteria for ARDS, indicating severe hypoxemia. Choice D, PAOP of more than 18 mm Hg, is used to differentiate between cardiogenic and non-cardiogenic causes of pulmonary edema, but it is not a direct diagnostic criterion for ARDS.