Nokea
The nurse is caring for a patient receiving continuous norepinephrine (Levophed) IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted?
- A. Heart rate is 58 beats/minute.
- B. Mean arterial pressure (MAP) is 56 mm Hg.
- C. Systemic vascular resistance (SVR) is elevated.
- D. Pulmonary artery wedge pressure (PAWP) is low.
Correct Answer: B
Rationale: The correct answer is B because a low Mean Arterial Pressure (MAP) indicates inadequate perfusion, which may require adjusting the norepinephrine infusion rate to increase blood pressure. A: A heart rate of 58 beats/minute is within a normal range and may not necessarily indicate a need for adjustment. C: Elevated Systemic Vascular Resistance (SVR) may be an expected response to norepinephrine and does not necessarily indicate a need for adjustment. D: A low Pulmonary Artery Wedge Pressure (PAWP) may indicate fluid volume deficit but does not directly relate to the need for adjusting norepinephrine infusion rate.
You may also like to solve these questions
The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include whic h intervention?
- A. Antiseptic oral care
- B. Bed rest with head of bed elevated
- C. Coughing and deep breathing
- D. Mobility
Correct Answer: D
Rationale: The correct answer is D: Mobility. Maintaining mobility helps prevent blood stasis, a leading factor in the development of pulmonary embolism. Movement promotes circulation, reducing the risk of blood clots.
A: Antiseptic oral care is important for oral hygiene but not directly related to preventing pulmonary embolism.
B: Bed rest with head of bed elevated can actually increase the risk of clots due to immobility.
C: Coughing and deep breathing are beneficial for preventing respiratory complications but do not address the underlying cause of pulmonary embolism.
The nurse is caring for a patient whose ventilator settings i nclude 15 cm H O of positive end-expiratory pressure (PEEP). The nurse understands that although beneficial, PEEP may result in what possible problem?
- A. Fluid overload secondary to decreased venous return.
- B. High cardiac index secondary to more efficient ventric ular function.
- C. Hypoxemia secondary to prolonged positive pressure a t expiration.
- D. Low cardiac output secondary to increased intrathoracic pressure
Correct Answer: D
Rationale: Rationale for Correct Answer (D - Low cardiac output secondary to increased intrathoracic pressure):
1. PEEP increases intrathoracic pressure, which can impede venous return to the heart.
2. Impaired venous return reduces preload, leading to decreased cardiac output.
3. Decreased cardiac output can result in inadequate tissue perfusion and oxygenation.
4. Therefore, PEEP may cause low cardiac output due to increased intrathoracic pressure.
Summary of Incorrect Choices:
A. Fluid overload is not directly related to PEEP but more to fluid administration or kidney function.
B. High cardiac index is unlikely as PEEP can decrease cardiac output.
C. Hypoxemia is not a direct result of PEEP but may occur due to other factors like inadequate ventilation or oxygenation settings.
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.
The family members are excited about being transferring t heir loved one from the critical care unit to the intermediate care unit. However, they are also fearful of the change in environment and nursing staff. To reduce relocation stress, the nurse ca n implement what intervention? (Select all that apply.)
- A. Arranging for the nurses on the intermediate care unit to give the family a tour of the new unit.
- B. Contacting the primary care provider to see if the patient can stay one additional day in the critical care unit so that the family can adjus t better to the idea of a transfer.
- C. Ensuring that the patient will be located near the nurse ’s station in the new unit.
- D. Inviting the nurse who will be assuming the patient’s care to meet with the patient and family in the critical care unit prior to transfer.
Correct Answer: A
Rationale: The correct answer is A (Arranging for the nurses on the intermediate care unit to give the family a tour of the new unit) because it helps familiarize the family with the new environment, alleviating their fears. The tour allows them to see where their loved one will be cared for, meet the nursing staff, and ask any questions they may have. This intervention promotes a smooth transition, reduces anxiety, and builds trust.
Choice B is incorrect because delaying the transfer doesn't address the fear of change and can prolong stress. Choice C is incorrect as proximity to the nurse's station may not necessarily reduce relocation stress for the family. Choice D is incorrect because meeting the new nurse in the current unit may not provide the same level of comfort and preparation compared to physically visiting the new unit.
The transplant clinic coordinator is evaluating relatives of a patient with end-stage renal disease, whose blood type is A positive, for suitability as aa bliirvb.icnogm /dteostn or for kidney transplantation. Which family member best qualifies for evaluation?
- A. A 65-year-old brother with a history of hypertension; b lood type A positive
- B. A 35-year-old female with a history of food allergies; blood type O negative
- C. A 14-year-old son, otherwise healthy with no history; blood type B negative
- D. A 70-year-old mother, with a history of sinus infection s; blood type A positive
Correct Answer: D
Rationale: The correct answer is D, the 70-year-old mother with blood type A positive. This choice is the best candidate for evaluation due to her blood type matching the patient's (A positive) for kidney transplantation. Age and medical history are also crucial factors in determining suitability. The 65-year-old brother (choice A) has hypertension, a significant risk factor. The 35-year-old female (choice B) with food allergies may have potential complications. The 14-year-old son (choice C) is underage and might not be a suitable donor due to age and the potential impact on his growth and development. In summary, choice D aligns with the matching blood type and age, making the mother the most suitable candidate for evaluation.