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The nurse is concerned that the patient will pull out the en dotracheal tube. As part of the nursing management, the nurse should obtain an order for what intervention?
- A. A Posey-type vest
- B. A higher dosage of lorazepam
- C. Propofol
- D. Soft wrist restraints
Correct Answer: A
Rationale: The correct answer is A. A Posey-type vest is a restraint designed to prevent patients from pulling out medical devices like endotracheal tubes, ensuring their safety. It is a less restrictive option compared to wrist restraints and sedatives (B and C), which can have adverse effects and may not directly address the concern of tube removal. Using a Posey-type vest promotes patient autonomy by allowing some movement while still providing the necessary protection.
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The nurse is caring for a patient receiving continuous norepinephrine (Levophed) IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted?
- A. Heart rate is 58 beats/minute.
- B. Mean arterial pressure (MAP) is 56 mm Hg.
- C. Systemic vascular resistance (SVR) is elevated.
- D. Pulmonary artery wedge pressure (PAWP) is low.
Correct Answer: B
Rationale: The correct answer is B because a low Mean Arterial Pressure (MAP) indicates inadequate perfusion, which may require adjusting the norepinephrine infusion rate to increase blood pressure. A: A heart rate of 58 beats/minute is within a normal range and may not necessarily indicate a need for adjustment. C: Elevated Systemic Vascular Resistance (SVR) may be an expected response to norepinephrine and does not necessarily indicate a need for adjustment. D: A low Pulmonary Artery Wedge Pressure (PAWP) may indicate fluid volume deficit but does not directly relate to the need for adjusting norepinephrine infusion rate.
A critically ill patient experiences stress and anxiety from many factors. Treatment of the patient focuses on reducing stressors and providing supportive care such as nutrition, oxygenation, pain management, control of anxiety, and specific care of the illness or injury. What is the best rationale for these interventions?
- A. Helps to support the patients immune system
- B. Part of good nursing care
- C. Mandated by hospital policy
- D. Reassures the patient and family
Correct Answer: A
Rationale: The correct answer is A: Helps to support the patient's immune system. Providing supportive care such as nutrition, oxygenation, pain management, and anxiety control can help reduce stress, which in turn supports the immune system. Stress weakens the immune system, making the patient more vulnerable to infections and complications. By addressing stress and anxiety through supportive care, the patient's immune system is better able to function optimally, aiding in the recovery process.
Choices B, C, and D are incorrect because:
B: Part of good nursing care - While supportive care is indeed part of good nursing care, the key rationale for these interventions in a critically ill patient is to support the immune system, not just to provide good nursing care.
C: Mandated by hospital policy - Hospital policies may dictate certain aspects of care, but the primary goal of these interventions is to support the patient's immune system, not just to comply with hospital policies.
D: Reassures the patient and family - While providing reass
The nurse is caring for a patient who sustained a head injury and is unresponsive to painful stimuli. Which intervention is most appropriate while bathaibnirgb. ctohme/ tpesatt ient?
- A. Ask a family member to help you bathe the patient, and discuss the family structure with the family member during the procedure .
- B. Because the patient is unconscious, complete care as q uickly and quietly as possible.
- C. Inform the patient of the day and time, and what kind o f care you are providing.
- D. Turn the television on to the evening news so that you and the patient can be updated to current events.
Correct Answer: B
Rationale: The correct answer is B: Because the patient is unconscious, complete care as quickly and quietly as possible. This is the most appropriate intervention as it prioritizes the patient's comfort and minimizes unnecessary stimulation. Performing care quickly reduces the time the patient is exposed to potentially uncomfortable procedures. Being quiet also helps create a calming environment for the patient, which is important for someone who is unresponsive.
Explanation for other choices:
A: Asking a family member to help and discussing family structure is not appropriate as it can be intrusive and may not be relevant or beneficial to the patient's care.
C: Informing the patient of the day and time is unnecessary as the patient is unresponsive. Providing care is more crucial than updating the patient.
D: Turning on the television is inappropriate as it introduces unnecessary noise and distraction, which can be overwhelming for an unresponsive patient.
The nurse notes premature ventricular contractions (PVCs) while suctioning a patient’s endotracheal tube. Which action by the nurse is a priority?
- A. Decrease the suction pressure to 80 mm Hg.
- B. Document the dysrhythmia in the patient’s chart.
- C. Stop and ventilate the patient with 100% oxygen.
- D. Give antidysrhythmic medications per protocol.
Correct Answer: C
Rationale: The correct answer is C: Stop and ventilate the patient with 100% oxygen. This is the priority action because PVCs can lead to life-threatening arrhythmias and inadequate oxygenation. By stopping suctioning and providing 100% oxygen, the nurse ensures proper oxygenation and ventilation, which takes precedence over addressing the dysrhythmia itself. Decreasing suction pressure (choice A) may not address the underlying issue and could potentially harm the patient. Documenting the dysrhythmia (choice B) is important but not as urgent as ensuring adequate oxygenation. Giving antidysrhythmic medications (choice D) should be done under the direction of a healthcare provider and is not the first-line intervention in this situation.
The patient is admitted with complaints of general malaise and fatigue, along with a decreased urinary output. The patient’s urinalysis shows coarse, muddy brown granular casts and hematuria. The nurse determines that the patient has:
- A. acute kidney injury from a prerenal condition.
- B. acute kidney injury from postrenal obstruction.
- C. intrarenal disease, probably acute tubular necrosis.
- D. a urinary tract infection.
Correct Answer: C
Rationale: The correct answer is C: intrarenal disease, probably acute tubular necrosis. The patient's symptoms of general malaise, fatigue, decreased urinary output, along with the presence of coarse, muddy brown granular casts and hematuria in the urinalysis indicate kidney damage. Acute tubular necrosis is a common cause of acute kidney injury characterized by damage to the renal tubules, leading to impaired kidney function. The presence of granular casts and hematuria suggests tubular injury and bleeding within the kidney. Choices A and B are incorrect as they refer to prerenal and postrenal causes of kidney injury, respectively, which do not align with the patient's symptoms and urinalysis findings. Choice D is incorrect as a urinary tract infection would typically present with different symptoms and urinalysis findings.