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The nurse is caring for a patient with an admitting diagnosis of congestive failure. While attempting to obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and tachypneic. What is the best action by the nurse?
- A. Limit the patient’s supine position to no more than 10 seconds.
- B. Administer anxiety medications while recording the pressure.
- C. Encourage the patient to take slow deep breaths while asbuirpb.icnoem./ test
- D. Elevate the head of the bed 45 degrees while recording pressures.
Correct Answer: D
Rationale: The correct answer is D: Elevate the head of the bed 45 degrees while recording pressures.
Rationale:
1. Elevating the head of the bed will help improve the patient's breathing by reducing the pressure on the diaphragm.
2. This position will also help alleviate the patient's anxiety and tachypnea, promoting better oxygenation.
3. Recording pressures in this position will provide accurate data for monitoring the patient's condition.
Summary:
A: Limiting the supine position to 10 seconds does not address the underlying issues causing the patient's anxiety and tachypnea.
B: Administering anxiety medications without addressing the positioning issue may not effectively manage the patient's symptoms.
C: Encouraging the patient to take slow deep breaths is helpful, but changing the position of the patient is more crucial in this situation.
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A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. Spontaneous re spirations are 12 breaths/min. The patient receives a dose of morphine sulfate, and now respi rations decrease to 4 breaths/min. What adjustments may need to be made to the patient’s ve ntilator settings?
- A. Add positive end-expiratory pressure (PEEP).
- B. Add pressure support.
- C. Change to assist/control ventilation at a rate of 4 breathabsi/rmb.cionm. /test
- D. Increase the synchronized intermittent mandatory ventilation respiratory rate.
Correct Answer: C
Rationale: The correct answer is C: Change to assist/control ventilation at a rate of 4 breaths/min. When the patient's spontaneous respirations decrease to match the ventilator rate, it indicates that the patient is not actively participating in breathing. Changing to assist/control ventilation allows the patient to trigger breaths when they desire, ensuring a more synchronized and comfortable breathing pattern.
A: Adding PEEP may help improve oxygenation but is not directly related to the issue of decreased spontaneous respirations.
B: Adding pressure support provides additional support during inspiration but does not address the underlying issue of decreased spontaneous respirations.
D: Increasing the SIMV respiratory rate would not address the patient's decreased spontaneous respirations and could potentially lead to overventilation.
In determining the glomerular filtration rate (GFR) or creatinine clearance, a 24-hour urine is obtained. If a reliable 24-hour urine collection is not possible,
- A. it is not possible to determine the GFR.
- B. the BUN may be used to determine renal function.
- C. an elevated BUN/creatinine ratio can be used.
- D. a standardized formula may be used to calculate GFR.
Correct Answer: D
Rationale: The correct answer is D because when a reliable 24-hour urine collection is not possible, a standardized formula can be used to estimate GFR. The Cockcroft-Gault equation or the Modification of Diet in Renal Disease (MDRD) equation are commonly used formulas to estimate GFR based on serum creatinine levels, age, gender, and race. These formulas provide a reasonable estimation of kidney function in the absence of a 24-hour urine collection.
Choice A is incorrect because there are alternative methods available to estimate GFR. Choice B is incorrect because BUN alone is not sufficient to accurately determine renal function. Choice C is incorrect because an elevated BUN/creatinine ratio is not a direct measure of GFR and may be influenced by factors other than kidney function, such as hydration status or liver function.
A patient with terminal cancer reports a sudden onset of severe pain. Which intervention should the nurse implement first?
- A. Assess the patient’s pain using a standardized pain scale.
- B. Administer a PRN dose of prescribed analgesic.
- C. Notify the healthcare provider about the patient’s pain.
- D. Reposition the patient to enhance comfort.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient’s pain using a standardized pain scale. The first step is to assess the severity and nature of the pain to determine the appropriate intervention. This allows the nurse to understand the pain intensity and characteristics, which guides the choice of analgesic and dosing. Administering analgesics (B) without proper assessment can lead to inappropriate treatment. Notifying the healthcare provider (C) is important but assessing the pain should come first. Repositioning the patient (D) may provide comfort but addressing the pain directly is the priority.
Comparing the patient’s current (home) medications with those ordered during hospitalization and communicating a complete list of medications to the next care provider when the patient is transferred within an organization or to another setting a re strategies toward best achieving what patient related goal?
- A. Improving accuracy of patient identification.
- B. Preventing errors related to look-alike and sound-alike medications.
- C. Reconciling medications across the continuum of care.
- D. Reducing harms associated with administration of anti coagulants.
Correct Answer: C
Rationale: Step 1: Reconciling medications is essential for patient safety as it involves comparing current and ordered medications to ensure accuracy.
Step 2: This process helps prevent medication errors, adverse drug reactions, and duplications across different care settings.
Step 3: Communicating a complete list of medications to the next care provider ensures continuity of care and reduces the risk of medication discrepancies.
Step 4: By reconciling medications across the continuum of care, healthcare providers can better coordinate patient care and optimize treatment outcomes.
In summary, choice C is correct as it focuses on medication reconciliation to improve patient safety and care coordination. Choices A, B, and D are incorrect as they do not directly address the comprehensive process of reconciling medications across care settings.
The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action indicates that the new RN is safe?
- A. The RN plans to suction the patient every 1 to 2 hours.
- B. The RN uses a closed-suction technique to suction the patient.
- C. The RN tapes the connection between the ventilator tubing and the ET.
- D. The RN changes the ventilator circuit tubing routinely every 48 hours.
Correct Answer: B
Rationale: The correct answer is B: The RN uses a closed-suction technique to suction the patient. This is the safe action because closed-suction technique minimizes the risk of ventilator-associated infections by maintaining a closed system during suctioning, reducing the exposure to pathogens. Closed-suction systems also help maintain lung compliance and oxygenation levels during the suctioning process.
Rationale: Option A is incorrect because suctioning every 1 to 2 hours may be too frequent and can lead to hypoxia and mucosal damage. Option C is incorrect as taping the connection between the ventilator tubing and ET can interfere with the proper functioning of the ventilator and increase the risk of disconnection. Option D is incorrect because changing ventilator circuit tubing routinely every 48 hours is not evidence-based practice and can increase the risk of contamination and unnecessary costs.