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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.
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The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT). In doing so, the nurse should
- A. assess that the blood tubing is warm to the touch.
- B. assess the hemofilter every 6 hours for clotting.
- C. cover the dialysis lines to protect them from light.
- D. use clean technique during vascular access dressing changes.
Correct Answer: B
Rationale: The correct answer is B because assessing the hemofilter every 6 hours for clotting is essential in ensuring the effectiveness of CRRT. Clotting can obstruct blood flow, leading to treatment inefficiency and potential harm to the patient. This step helps the nurse to promptly address any clotting issues and prevent complications.
A: Assessing that the blood tubing is warm to the touch is not a standard practice for monitoring CRRT and does not provide relevant information about the treatment's effectiveness.
C: Covering the dialysis lines to protect them from light is not a priority in monitoring CRRT. Light exposure is not a common concern in this context.
D: Using clean technique during vascular access dressing changes is important for infection prevention but is not directly related to monitoring the effectiveness of CRRT.
Ideally, by whom and when should an advance directive be developed?
- A. Family, if the patient is in critical condition.
- B. Patient as part of the hospital admission process.
- C. Patient before illness or impairment occurs.
- D. Patient’s healthcare surrogate.
Correct Answer: C
Rationale: Step-by-step rationale for choice C:
1. Advance directives should be made by the patient to reflect their wishes.
2. Developing it before illness ensures clarity and avoids confusion.
3. Patients may not be able to make informed decisions in critical conditions.
4. Family or surrogates may not accurately represent the patient's wishes.
Summary:
A - Family in critical condition may not know the patient's wishes.
B - Hospital admission process may be too late for clear decision-making.
D - Healthcare surrogate may not fully understand the patient's preferences.
The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document that indicates a successful outcome?
- A. Demonstrates adequate fluid intake and output.
- B. Verbalizes abdominal comfort without pressure.
- C. Drinks 240 mL of fluid five times during the shift.
- D. Voids at least 1000 mL between 7 am and 3 pm.
Correct Answer: C
Rationale: Step 1: The objective is for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm.
Step 2: Choice C states that the client drinks 240 mL of fluid five times during the shift, totaling 1200 mL (240 mL x 5) which exceeds the required amount.
Step 3: Therefore, choice C is the correct answer as it demonstrates successful achievement of the objective by ensuring the client has ingested enough fluid within the specified time frame.
Step 4: Choices A, B, and D are incorrect as they do not directly address the specific objective of fluid intake set for the client. Option A focuses on intake and output, option B relates to abdominal comfort, and option D is about voiding, none of which directly address the specified objective of fluid ingestion.
When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient’s temperature is 101.8°F. What should the nurse plan to do next?
- A. Give analgesics and antibiotics as ordered.
- B. Discontinue the catheter and culture the tip.
- C. Change the flush system and monitor the site.
- D. Check the site more frequently for any swelling.
Correct Answer: B
Rationale: The correct answer is B: Discontinue the catheter and culture the tip. The patient's symptoms indicate a possible catheter-related infection. Discontinuing the catheter will prevent further infection spread. Culturing the tip will identify the specific pathogen causing the infection, guiding appropriate antibiotic therapy. Choice A is incorrect because giving analgesics alone will not address the underlying infection. Choice C is incorrect as changing the flush system is not a priority when infection is suspected. Choice D is incorrect as checking the site more frequently does not address the need for immediate action to address the infection.
The nurse is assisting with endotracheal intubation of the p atient and recognizes that the procedure will be done in what order? (Put a comma and s pace between each answer choice.)
- A. Assess balloon on endotracheal tube for symmetry and laebairkb.sc.o m/test
- B. Assess lung fields for bilateral expansion.
- C. Inflate balloon of endotracheal tube.
- D. Insert endotracheal tube with laryngoscope and blade.
Correct Answer: D
Rationale: The correct answer is D. The first step in endotracheal intubation is to insert the endotracheal tube with a laryngoscope and blade to visualize the vocal cords and guide the tube into the trachea. This ensures proper placement of the tube for effective ventilation. Assessing the balloon symmetry (Choice A) and lung fields (Choice B) would come after the tube is successfully inserted. Inflating the balloon of the endotracheal tube (Choice C) should be the last step to secure the tube in place.