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 charge nurse is supervising the care of four critical ca re patients being monitored using invasive hemodynamic modalities. Which patient should t he charge nurse evaluate first?
- A. A patient in cardiogenic shock with a cardiac output (CabOirb). coofm 2/te.0st L/min
- B. A patient with a pulmonary artery systolic pressure (PA P) of 20 mm Hg
- C. A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg
- D. A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg
Correct Answer: A
Rationale: The correct answer is A because the patient in cardiogenic shock with a cardiac output of 2.0 L/min is experiencing a life-threatening condition that requires immediate evaluation. Cardiogenic shock indicates poor cardiac function, which can lead to multi-organ failure. Monitoring cardiac output is crucial in managing these patients.
Choice B is incorrect because a pulmonary artery systolic pressure of 20 mm Hg is within normal range and does not indicate an immediate life-threatening condition.
Choice C is incorrect because a CVP of 6 mm Hg in a hypovolemic patient may indicate volume depletion, but it is not as urgent as the patient in cardiogenic shock.
Choice D is incorrect because a PAOP of 10 mm Hg is within normal range and does not suggest an immediate critical condition.
The nurse is caring for a patient who sustained a head injury and is unresponsive to painful stimuli. Which intervention is most appropriate while bathaibnirgb. ctohme/ tpesatt ient?
- A. Ask a family member to help you bathe the patient, and discuss the family structure with the family member during the procedure .
- B. Because the patient is unconscious, complete care as q uickly and quietly as possible.
- C. Inform the patient of the day and time, and what kind o f care you are providing.
- D. Turn the television on to the evening news so that you and the patient can be updated to current events.
Correct Answer: B
Rationale: The correct answer is B: Because the patient is unconscious, complete care as quickly and quietly as possible. This is the most appropriate intervention as it prioritizes the patient's comfort and minimizes unnecessary stimulation. Performing care quickly reduces the time the patient is exposed to potentially uncomfortable procedures. Being quiet also helps create a calming environment for the patient, which is important for someone who is unresponsive.
Explanation for other choices:
A: Asking a family member to help and discussing family structure is not appropriate as it can be intrusive and may not be relevant or beneficial to the patient's care.
C: Informing the patient of the day and time is unnecessary as the patient is unresponsive. Providing care is more crucial than updating the patient.
D: Turning on the television is inappropriate as it introduces unnecessary noise and distraction, which can be overwhelming for an unresponsive patient.
A critically ill patient who is intubated and agitated is restrained with soft wrist restraints. Based on research findings, what is the best nursing action?
- A. Maintain the restraints to protect patient safety.
- B. Remove the restraints periodically to check skin integrity.
- C. Remove the restraints periodically for range of motion.
- D. Assess and intervene for causes of agitation. Answer Key
Correct Answer: D
Rationale: The correct answer is D: Assess and intervene for causes of agitation. In a critically ill patient, agitation while intubated could indicate underlying issues like pain, delirium, or inadequate sedation. By assessing and addressing the root cause of agitation, the nurse can improve patient comfort and prevent potential harm from restraints. Removing restraints periodically for skin integrity (B) and range of motion (C) is important but should not be the primary focus when agitation is present. Maintaining restraints (A) without addressing the agitation could lead to increased distress and potential complications.
The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take?
- A. Withhold the medication and contact the healthcare provider.
- B. Give the medication dosage as scheduled.
- C. Assess respiratory rate for one minute next.
- D. Wait 30 minutes and give half of the dosage of medication.
Correct Answer: A
Rationale: The correct answer is A. Infants typically have higher resting heart rates than adults, so a pulse rate of 89 beats/minute for an infant may indicate bradycardia. Digoxin can further lower the heart rate, leading to potential adverse effects like arrhythmias. Therefore, withholding the medication and contacting the healthcare provider is crucial to ensure the safety of the infant.
Choice B is incorrect because administering digoxin without addressing the elevated pulse rate can be dangerous. Choice C is incorrect as assessing respiratory rate does not address the immediate concern of the elevated pulse rate. Choice D is also incorrect as waiting and giving half of the dosage may further exacerbate the situation.
Intrapulmonary shunting refers to what outcome?
- A. Alveoli that are not perfused.
- B. Blood that is shunted from the left side of the heart to t he right and causes heart failure.
- C. Blood that is shunted from the right side of the heart to the left without oxygenation.
- D. Shunting of blood supply to only one lung.
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Intrapulmonary shunting refers to blood bypassing the normal oxygenation process in the lungs.
2. Choice C describes blood being shunted from the right side of the heart (deoxygenated blood) to the left side without oxygenation, leading to systemic circulation without oxygenation.
3. Choices A, B, and D do not accurately describe intrapulmonary shunting as they focus on other concepts like alveolar perfusion, heart failure, and unilateral lung blood supply, respectively.