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The nurse is caring for four patients on the progressive car e unit. Which patient is at greatest risk for developing delirium?
- A. 36-year-old recovering from a motor vehicle crash with an alcohol withdrawal protocol.
- B. 54-year-old postoperative aortic aneurysm resection with an elevated creatinine level
- C. 86-year-old from nursing home, postoperative from coalboirnb .croemse/tecstti on
- D. 95-year-old with community-acquired pneumonia; fam ily has brought in eyeglasses and hearing aid
Correct Answer: C
Rationale: The correct answer is C, the 86-year-old postoperative from colonic resection. This patient is at the greatest risk for delirium due to being elderly, having undergone surgery, and having a history of being from a nursing home. These factors contribute to an increased susceptibility to delirium.
A: The 36-year-old with alcohol withdrawal may be at risk for delirium tremens, but the older age of the patient in choice C places them at higher risk.
B: The 54-year-old with an elevated creatinine level postoperative is at risk for complications, but age and history of nursing home placement increase the risk for delirium in choice C.
D: The 95-year-old with community-acquired pneumonia is at risk for delirium, but the combination of age, surgery, and nursing home history in choice C presents a greater risk.
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In assessing a patient, the nurse understands that what sym ptomology is an early sign of hypoxemia?
- A. Clubbing of nail beds
- B. Cyanosis
- C. Hypotension
- D. Restlessness
Correct Answer: D
Rationale: Step 1: Restlessness is an early sign of hypoxemia due to the body's response to low oxygen levels.
Step 2: Restlessness occurs as the body tries to increase oxygen intake.
Step 3: Other choices are incorrect because clubbing and cyanosis are late signs, while hypotension is not a specific early sign of hypoxemia.
A young man has just arrived at the ICU from out of town and received news that his girlfriend, who is admitted there, likely only has a few days left to live. Which of the following would be the best approach for the nurse to take in caring for the needs of this young man?
- A. Recommending that he go home and rest
- B. Giving him unrestricted visiting hours with the patient
- C. Suggesting that he meet with the hospital chaplain
- D. Recommending that he ask the doctor to evaluate the patients pain control measures
Correct Answer: C
Rationale: The correct answer is C: Suggesting that he meet with the hospital chaplain. This approach is best as it addresses the young man's emotional and spiritual needs during a difficult time. The chaplain can provide comfort, support, and guidance in coping with his girlfriend's situation. This option focuses on holistic care and acknowledges the importance of emotional well-being.
A: Recommending that he go home and rest is not the best approach as it dismisses the young man's emotional distress.
B: Giving him unrestricted visiting hours with the patient may not be appropriate as it can be overwhelming and may not address his emotional needs effectively.
D: Recommending that he ask the doctor to evaluate the patient's pain control measures is important but does not directly address the young man's emotional needs in this situation.
A nurse is the only one in the ICU who has not achieved certification in critical care nursing. She often will ask her fellow nurses what to do in caring for a patient because she doubts the accuracy of her knowledge and her intuition. She loves her work but wishes she could do it with a greater level of competence. What is the most important effect that obtaining certification would likely have on the nurses practice?
- A. Recognition by peers
- B. Increase in salary and rank
- C. More flexibility in seeking employment
- D. Increased confidence in making decisions
Correct Answer: D
Rationale: The correct answer is D: Increased confidence in making decisions. Obtaining certification in critical care nursing would likely enhance the nurse's knowledge and skills, leading to increased confidence in making clinical decisions. This confidence would stem from the rigorous training and education required to achieve certification, as well as the validation of her expertise in critical care nursing. With increased confidence, the nurse would be more self-assured in her abilities, leading to improved patient care outcomes.
Choice A: Recognition by peers is not the most important effect because while recognition is a positive outcome, it may not directly impact the nurse's ability to provide better patient care.
Choice B: Increase in salary and rank is not the most important effect because while financial benefits are important, the primary focus of obtaining certification should be on improving competence and patient care.
Choice C: More flexibility in seeking employment is not the most important effect because while certification may open up more job opportunities, the main benefit should be on enhancing the nurse's skills and confidence in providing quality
A 53-year-old, 80-kg patient is admitted to the cardiac sur gical intensive care unit after cardiac surgery with the following arterial blood gas (ABG ) levels. What is the nurse’s interpretation of these values? pH 7.4 PaCO 40 mm Hg Bicarbonate 24 mEq/L PaO 95 mm Hg O saturation 97% Respirations 20 breaths per minute
- A. Compensated metabolic acidosis
- B. Metabolic alkalosis
- C. Normal ABG values
- D. Respiratory acidosis
Correct Answer: C
Rationale: The correct interpretation is C: Normal ABG values.
1. pH is within the normal range of 7.35-7.45.
2. PaCO2 is 40 mm Hg, within the normal range of 35-45 mm Hg.
3. Bicarbonate is 24 mEq/L, within the normal range of 22-26 mEq/L.
4. PaO2 is 95 mm Hg, within the normal range of 80-100 mm Hg.
5. Oxygen saturation is 97%, which is normal.
6. Respirations are also within the normal range at 20 breaths per minute.
Overall, all values fall within the normal range, indicating a well-maintained acid-base balance. Other choices are incorrect because there are no abnormalities that would suggest compensated metabolic acidosis, metabolic alkalosis, or respiratory acidosis based on the given ABG values.
A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse should provide the patient with what explanation?
- A. “I’m going to contact the pharmacist to see if you can take this medication by mouth.”
- B. “This injection is being given to prevent blood clots fr om forming.”
- C. “This medication will dissolve any blood clots you migabhirtb .gcoemt./”te st
- D. “I will contact your primary care provide to discuss wh y you are getting this medication.” t
Correct Answer: B
Rationale: The correct answer is B: “This injection is being given to prevent blood clots from forming.” Enoxaparin is an anticoagulant used to prevent blood clots. It is administered through injection, not orally (A). Enoxaparin does not dissolve existing blood clots (C). Contacting the primary care provider to discuss the medication is not necessary in this scenario (D). The correct choice emphasizes the purpose of enoxaparin in preventing new blood clots.