Nokea
The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient’s urine output has been less than 20 mL/hour for the past 2 hours. The patient’s blood pressure is 100/60 mm Hg, and the pulse is 110 beats/min. Previously, the pulse was 90 beats/min with a blood pressure of 120/80 mm Hg. The nurse should
- A. contact the provider and expect a prescription for a normal saline bolus.
- B. wait until the provider makes rounds to report the assessment findings.
- C. continue to evaluate urine output for 2 more hours.
- D. ignore the urine output, as this is most likely postrenal in origin.
Correct Answer: A
Rationale: The correct answer is A: contact the provider and expect a prescription for a normal saline bolus. The patient is showing signs of hypovolemia with decreased urine output, low blood pressure, and elevated heart rate. This indicates inadequate perfusion and potential hypovolemic shock. Administering a normal saline bolus will help restore intravascular volume and improve perfusion. Waiting for the provider to make rounds (option B) could delay necessary intervention. Continuing to evaluate urine output for 2 more hours (option C) is not appropriate given the patient's current condition. Ignoring the urine output (option D) is dangerous as it could lead to further complications.
You may also like to solve these questions
The nurse is assessing the critically ill patient for delirium . The nurse recognizes which characteristics that indicate hyperactive delirium? (Select aabllir bt.hcaomt /atepstp ly.)
- A. Agitation
- B. Apathy
- C. Biting
- D. Hitting
Correct Answer: A
Rationale: The correct answer is A: Agitation. In hyperactive delirium, patients often exhibit restlessness, agitation, and hyperactivity. This behavior is a key characteristic indicating hyperactive delirium. Apathy (B), biting (C), and hitting (D) are not typically associated with hyperactive delirium. Apathy may be seen in hypoactive delirium, while biting and hitting are not specific indicators of delirium subtypes. Therefore, the correct choice is A as it aligns with the typical presentation of hyperactive delirium.
What is the most important nursing intervention for patien ts who receive neuromuscular blocking agents?
- A. Administer sedatives in conjunction with the neuromu as bc iu rbl .a cor m b /tl eo sc t king agents.
- B. Assess neurological status every 30 minutes.
- C. Avoid interaction with the patient, because he or she won’t be able to hear.
- D. Restrain the patient to avoid self-extubation.
Correct Answer: B
Rationale: The correct answer is B: Assess neurological status every 30 minutes. This intervention is crucial for patients receiving neuromuscular blocking agents to monitor for any adverse effects such as respiratory depression or paralysis. Regular assessments help ensure early detection of complications and prompt intervention.
A: Administering sedatives in conjunction with neuromuscular blocking agents can potentiate respiratory depression and lead to respiratory compromise.
C: Avoiding interaction with the patient is not appropriate as communication and patient interaction are important aspects of nursing care.
D: Restraint should be avoided as it can increase the risk of complications such as pressure ulcers, anxiety, and decreased respiratory function.
Overall, regular neurological assessments are essential for ensuring patient safety and prompt intervention in case of any complications.
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.
Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first?
- A. Insert a large-bore orogastric tube.
- B. Assist with the intubation of the patient.
- C. Prepare a 60-mL syringe with saline.
- D. Give the first dose of activated charcoal.
Correct Answer: B
Rationale: The correct answer is B: Assist with the intubation of the patient. In this scenario, the patient is unconscious and has ingested a potentially harmful substance. Intubation is the first priority to maintain the patient's airway and ensure adequate oxygenation. This step is crucial in preventing aspiration of gastric contents and securing the patient's respiratory status. Inserting a large-bore orogastric tube (choice A) is not the priority as airway management takes precedence. Preparing a syringe with saline (choice C) is unnecessary at this stage. Giving the first dose of activated charcoal (choice D) should only be done after securing the airway to prevent aspiration.
A 75-year-old patient, who suffered a massive stroke 3 weeks ago, has been unresponsive and
- A. The primary health care provider has approached the spouse regarding placement of a perma nent feeding tube. The spouse states that the patient never wanted to be kept alive by tub es and personally didn’t want what was being done. After holding a family conference with th e spouse, the medical team concurs and the feeding tube is not placed. What term would be used to describe this situation?
- B. Euthanasia
- C. Palliative care
- D. Withdrawal of life support
Correct Answer: E
Rationale: Step 1: The scenario describes a decision made based on the patient's previously expressed wishes.
Step 2: The decision aligns with the principle of respecting patient autonomy.
Step 3: The term that best describes this situation is "Advance Directive."
Summary:
- A: Incorrect, as it involves actively ending the patient's life without their consent.
- B: Incorrect, as euthanasia involves intentionally causing death to relieve suffering.
- C: Incorrect, as palliative care focuses on improving quality of life for the patient.
- D: Incorrect, as withdrawal of life support involves discontinuing medical interventions, not honoring the patient's wishes.