Nokea
The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.)
- A. high Fowler’s.
- B. side lying with head of bed elevated.
- C. sitting in a chair.
- D. supine with the bed flat.
Correct Answer: A
Rationale: The correct answer is A: high Fowler's position. This position promotes optimal lung expansion by allowing the chest to expand fully, improving oxygenation. It also helps reduce the work of breathing. Side lying with the head of the bed elevated (B) may not provide the same level of lung expansion. Sitting in a chair (C) may not be suitable for a patient in acute respiratory failure as it may not provide adequate support for breathing. Supine with the bed flat (D) can worsen respiratory distress by limiting lung expansion.
You may also like to solve these questions
The nurse is caring for a mechanically ventilated patient following bilateral lung transplantation. When planning the care of this patient, what is the priority nursing intervention?
- A. Thirty-degree elevation of head of bed
- B. Endotracheal suctioning as needed
- C. Frequent side to side repositioning
- D. Sequential compression stockings
Correct Answer: A
Rationale: The correct answer is A: Thirty-degree elevation of the head of the bed. This is the priority nursing intervention for a mechanically ventilated patient following bilateral lung transplantation because it helps optimize ventilation-perfusion matching, reduces the risk of aspiration, and improves oxygenation. Elevating the head of the bed also decreases the risk of ventilator-associated pneumonia.
B: Endotracheal suctioning as needed is important but not the priority intervention in this case.
C: Frequent side to side repositioning is important for preventing pressure ulcers but is not the priority for a ventilated patient post-lung transplant.
D: Sequential compression stockings are used for preventing deep vein thrombosis, which is important but not the priority in this scenario.
A nurse is the only one in the ICU who has not achieved certification in critical care nursing. She often will ask her fellow nurses what to do in caring for a patient because she doubts the accuracy of her knowledge and her intuition. She loves her work but wishes she could do it with a greater level of competence. What is the most important effect that obtaining certification would likely have on the nurses practice?
- A. Recognition by peers
- B. Increase in salary and rank
- C. More flexibility in seeking employment
- D. Increased confidence in making decisions
Correct Answer: D
Rationale: The correct answer is D: Increased confidence in making decisions. Obtaining certification in critical care nursing would likely enhance the nurse's knowledge and skills, leading to increased confidence in making clinical decisions. This confidence would stem from the rigorous training and education required to achieve certification, as well as the validation of her expertise in critical care nursing. With increased confidence, the nurse would be more self-assured in her abilities, leading to improved patient care outcomes.
Choice A: Recognition by peers is not the most important effect because while recognition is a positive outcome, it may not directly impact the nurse's ability to provide better patient care.
Choice B: Increase in salary and rank is not the most important effect because while financial benefits are important, the primary focus of obtaining certification should be on improving competence and patient care.
Choice C: More flexibility in seeking employment is not the most important effect because while certification may open up more job opportunities, the main benefit should be on enhancing the nurse's skills and confidence in providing quality
After the change-of-shift report, which patient should the progressive care nurse assess first?
- A. Patient who was extubated in the morning and has a temperature of 101.4°F (38.6°C).
- B. Patient with bilevel positive airway pressure (BiPAP) for sleep apnea whose respiratory rate is 16.
- C. Patient with arterial pressure monitoring who is 2 hours post percutaneous coronary intervention and needs to void.
- D. Patient who is receiving IV heparin for venous thromboembolism and has a partial thromboplastin time (PTT) of 98 seconds.
Correct Answer: D
Rationale: The correct answer is D. The patient receiving IV heparin with a PTT of 98 seconds is at risk for bleeding due to the therapeutic range of 60-80 seconds. Assessing this patient first is crucial to prevent potential bleeding complications. A high PTT indicates the blood is not clotting properly, increasing the risk of bleeding. Prompt assessment and possible adjustment of heparin infusion are needed.
A: The patient with a temperature of 101.4°F may have a fever but is not at immediate risk compared to the patient with a high PTT.
B: The patient on BiPAP with a respiratory rate of 16 is stable and does not require immediate assessment.
C: The patient post-percutaneous coronary intervention needing to void is a routine need and does not require immediate attention compared to the patient with a critical lab value.
Which hemodynamic parameter is most appropriate for the nurse to monitor to determine the effectiveness of medications given to a patient to reduce left ventricular afterload?
- A. Mean arterial pressure (MAP)
- B. Systemic vascular resistance (SVR)
- C. Pulmonary vascular resistance (PVR)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: B
Rationale: The correct answer is B: Systemic vascular resistance (SVR). SVR reflects the resistance the heart must overcome to pump blood into the systemic circulation. By monitoring SVR, the nurse can assess the effectiveness of medications aimed at reducing left ventricular afterload, as these medications work by dilating blood vessels and reducing resistance. An effective reduction in afterload would lead to a decrease in SVR.
A: Mean arterial pressure (MAP) is an indicator of perfusion pressure but may not directly reflect changes in afterload.
C: Pulmonary vascular resistance (PVR) is specific to the pulmonary circulation and not directly related to left ventricular afterload.
D: Pulmonary artery wedge pressure (PAWP) is a measure of left ventricular preload and filling pressures, not afterload.
The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will be most effective in addressing this problem?
- A. Increase suctioning to every hour.
- B. Reposition the patient every 1 to 2 hours.
- C. Add additional water to the patient’s enteral feedings.
- D. Instill 5 mL of sterile saline into the ET before suctioning.
Correct Answer: D
Rationale: The correct answer is D: Instill 5 mL of sterile saline into the ET before suctioning. This intervention helps to loosen and mobilize the thick secretions, making them easier to remove during suctioning. It is important to moisten the secretions to prevent mucosal damage and trauma during suctioning.
A: Increasing suctioning frequency can lead to mucosal damage and increased risk of infection.
B: Repositioning helps with ventilation and preventing pressure injuries, but it does not directly address the thick secretions.
C: Adding water to enteral feedings will not directly address the thick secretions in the ET.
In summary, instilling sterile saline into the ET before suctioning is the most effective intervention as it helps to loosen and mobilize thick secretions, making suctioning more effective and reducing the risk of mucosal damage.