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The nurse is caring for a patient who is orally intubated and on a mechanical ventilator. The nurse believes that the patient is experiencing excess anxiety. For this patient, what behavior best indicates anxiety?
- A. Restlessness
- B. Verbalization
- C. Increased respiratory rate
- D. Glasgow Coma Scale score of 3
Correct Answer: A
Rationale: The correct answer is A: Restlessness. Restlessness is a common behavioral indicator of anxiety in patients. In this scenario, a patient who is orally intubated and on a ventilator may not be able to verbally express anxiety, making restlessness a more prominent sign. Verbalization may not be possible due to intubation. While increased respiratory rate can be a symptom of anxiety, it is also a common physiological response in patients on mechanical ventilation. A Glasgow Coma Scale score of 3 indicates severe impairment of consciousness, not specifically anxiety.
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Identify which substances in the glomerular filtrate would indicate a problem with renal function. (Select all that apply.)
- A. Protein
- B. Sodium
- C. Creatinine
- D. Red blood cells
Correct Answer: A
Rationale: The presence of protein in the glomerular filtrate indicates a problem with renal function because in healthy kidneys, proteins are retained in the blood and not filtered into the urine. If protein is found in the filtrate, it suggests damage to the glomerular filtration barrier. Sodium, creatinine, and red blood cells are normally present in the filtrate and are not indicative of renal dysfunction. Sodium is freely filtered and reabsorbed, creatinine is a waste product of muscle metabolism excreted by the kidneys, and a small number of red blood cells may be filtered due to their small size. Therefore, protein in the glomerular filtrate is the most specific indicator of renal dysfunction.
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.
Which nursing actions are most important for a patient witahb irab .croigmh/tte srta dial arterial line? (Select all that apply.)
- A. Checking the circulation to the right hand every 2 hour s
- B. Maintaining a pressurized flush solution to the arterial line setup
- C. Monitoring the waveform on the monitor for dampenin g
- D. Restraining all four extremities with soft limb restraint s
Correct Answer: A
Rationale: Step 1: Checking circulation to the right hand is crucial for assessing perfusion and detecting potential complications.
Step 2: Arterial line placement can compromise blood flow, leading to ischemia if circulation is impaired.
Step 3: Monitoring circulation every 2 hours allows for early detection of issues and prompt intervention.
Step 4: This action ensures patient safety and prevents complications.
Summary:
- Choice B is incorrect as pressurized flush solution can increase the risk of complications.
- Choice C is incorrect as monitoring the waveform is important but not the most critical action.
- Choice D is incorrect as limb restraints can impede circulation and are unnecessary in this scenario.
When providing palliative care, the nurse must keep in mind that the family may include which of the following? (Select all that apply.)
- A. Unmarried life partners of same sex
- B. Unmarried life partners of opposite sex
- C. Roommates
- D. Close friends
Correct Answer: A
Rationale: The correct answer is A: Unmarried life partners of same sex. When providing palliative care, it's crucial to recognize and respect diverse family structures. Unmarried life partners of the same sex may form a significant familial bond, requiring support and involvement in care decisions. This choice aligns with the principles of inclusivity and non-discrimination in palliative care.
Incorrect choices:
B: Unmarried life partners of the opposite sex - This choice is incorrect as it limits the definition of family to only opposite-sex partners, excluding same-sex couples.
C: Roommates - While roommates may provide support, they do not necessarily have the same level of emotional and decision-making involvement as family members or life partners.
D: Close friends - While close friends can be important sources of support, they do not necessarily have the same legal or emotional ties as a life partner.
The nurse uses the Situation-Background-Assessment-Recommendation (SBAR) format to communicate a change in patient status to a healthcare provider. In which order should the nurse make the following statements?
- A. The patient needs to be evaluated immediately and may need intubation and mechanical ventilation.
- B. The patient was admitted yesterday with heart failure and has been receiving furosemide (Lasix) for diuresis, but urine output has been low.
- C. The patient has crackles audible throughout the posterior chest and the most recent oxygen saturation is 89%. Her condition is very unstable.
- D. This is the nurse on the surgical unit. After assessing the patient, I am very concerned about increased shortness of breath over the past hour.
Correct Answer: B
Rationale: Step 1: Start with Background - statement B provides relevant background information about the patient's current condition and why there is a need for communication.
Step 2: Move on to Situation - statement D sets the current situation where the nurse expresses concern about the patient's symptom.
Step 3: Next is Assessment - statement C details the nurse's assessment findings, highlighting the critical aspects of the patient's condition.
Step 4: End with Recommendation - statement A suggests the necessary action to be taken based on the assessment findings. This order ensures a clear and structured communication process.
Summary:
- Choice A is incorrect as the recommendation should come after providing background, situation, and assessment.
- Choice C is incorrect as assessment details should precede the patient's critical condition.
- Choice D is incorrect as the situation should be explained before expressing concern.