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The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include whic h intervention?
- A. Antiseptic oral care
- B. Bed rest with head of bed elevated
- C. Coughing and deep breathing
- D. Mobility
Correct Answer: D
Rationale: The correct answer is D: Mobility. Maintaining mobility helps prevent blood stasis, a leading factor in the development of pulmonary embolism. Movement promotes circulation, reducing the risk of blood clots.
A: Antiseptic oral care is important for oral hygiene but not directly related to preventing pulmonary embolism.
B: Bed rest with head of bed elevated can actually increase the risk of clots due to immobility.
C: Coughing and deep breathing are beneficial for preventing respiratory complications but do not address the underlying cause of pulmonary embolism.
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The nurse wishes to increase the use of evidence-based practice in the critical care unit where he works. What is a significant barrier to the implementation of evidence-based practice?
- A. Use of computerized records by the hospital
- B. Health Information Privacy and Portability Act (HIPPA)
- C. Lack of knowledge about literature searches
- D. Strong collaborative relationships in the work setting
Correct Answer: C
Rationale: Rationale:
The correct answer is C because lack of knowledge about literature searches hinders the ability to find and utilize evidence-based practice guidelines. Nurses need to be skilled in conducting literature searches to access relevant research. Choices A, B, and D are incorrect as they do not directly impede the implementation of evidence-based practice in the critical care unit.
Intrapulmonary shunting refers to what outcome?
- A. Alveoli that are not perfused.
- B. Blood that is shunted from the left side of the heart to t he right and causes heart failure.
- C. Blood that is shunted from the right side of the heart to the left without oxygenation.
- D. Shunting of blood supply to only one lung.
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Intrapulmonary shunting refers to blood bypassing the normal oxygenation process in the lungs.
2. Choice C describes blood being shunted from the right side of the heart (deoxygenated blood) to the left side without oxygenation, leading to systemic circulation without oxygenation.
3. Choices A, B, and D do not accurately describe intrapulmonary shunting as they focus on other concepts like alveolar perfusion, heart failure, and unilateral lung blood supply, respectively.
What is the most important outcome of effective communi cation?
- A. Demonstrating caring practices to family members.
- B. Ensuring that patient teaching is provided
- C. Meeting the diversity needs of patients.
- D. Reducing patient errors.
Correct Answer: D
Rationale: The correct answer is D because reducing patient errors is the most important outcome of effective communication in healthcare. Clear and accurate communication among healthcare providers and patients can prevent misunderstandings, leading to fewer errors in diagnosis, treatment, and medication administration. This ultimately improves patient safety and outcomes.
A: Demonstrating caring practices to family members is important but not the most crucial outcome of effective communication in healthcare.
B: Ensuring that patient teaching is provided is essential, but patient safety through error reduction takes precedence.
C: Meeting the diversity needs of patients is crucial for patient-centered care, but error reduction directly impacts patient safety, making it more critical.
The nurse is caring for a patient who is mechanically ventilated. The nurse understands that what statement should be considered when determining apapbrirob.pcormia/ttees tn ursing interventions?
- A. Communication with intubated patients is often difficult.
- B. Controlled ventilation is the preferred mode for most p atients.
- C. Patients with chronic obstructive pulmonary disease w ean easily from mechanical ventilation.
- D. Wrist restraints are applied to all patients to avoid self- extubation.
Correct Answer: A
Rationale: The correct answer is A because communication with intubated patients is often challenging due to the presence of an artificial airway, which hinders speech. This understanding is crucial when determining appropriate nursing interventions to ensure effective patient care.
Choice B is incorrect because different patients may require different modes of ventilation based on their specific condition, and controlled ventilation may not always be the preferred mode for all patients.
Choice C is incorrect as patients with chronic obstructive pulmonary disease often have difficulty weaning from mechanical ventilation due to their underlying respiratory condition.
Choice D is incorrect as wrist restraints are not applied to all patients on mechanical ventilation unless absolutely necessary for safety concerns, such as preventing self-extubation.
The patient’s potassium level is 7.0 mEq/L. Besides dialysis, which of the following actually reduces plasma potassium levels and total body potassium content safely in a patient with renal dysfunction?
- A. Sodium polystyrene sulfonate
- B. Sodium polystyrene sulfonate with sorbitol
- C. Regular insulin
- D. Calcium gluconate
Correct Answer: C
Rationale: Correct Answer: C - Regular insulin
Rationale:
1. Insulin promotes cellular uptake of potassium.
2. When insulin is administered, it moves potassium from extracellular to intracellular space.
3. This decreases plasma potassium levels safely.
4. Other options do not directly lower potassium levels in the same manner.
Summary of Other Choices:
A: Sodium polystyrene sulfonate - exchanges sodium for potassium in the intestines, not reducing total body potassium.
B: Sodium polystyrene sulfonate with sorbitol - similar to A, does not reduce total body potassium.
D: Calcium gluconate - does not directly lower potassium levels, used for treating hyperkalemia-induced cardiac toxicity.