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The nurse caring for a patient diagnosed with acute respiratory failure identifies “Risk for Ineffective Airway Clearance” as a nursing diagnosis. Wh at nursing intervention is relevant to this diagnosis?
- A. Elevate head of bed to 30 degrees.
- B. Obtain order for venous thromboembolism prophylaxi s.
- C. Provide adequate sedation.
- D. Reposition patient every 2 hours.
Correct Answer: A
Rationale: The correct answer is A: Elevate head of bed to 30 degrees. Elevating the head of the bed helps promote optimal airway clearance by facilitating drainage of secretions and reducing the risk of aspiration. This position also improves lung expansion and oxygenation. Choice B is important for preventing venous thromboembolism but not directly related to airway clearance. Choice C may not be appropriate as excessive sedation can impair airway clearance. Choice D is important for preventing pressure ulcers but does not directly address airway clearance.
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The nurse identifies a client's needs and formulates the nursing problem of, 'Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months.' Which short-term goal is best for this client?
- A. Verbalize understanding of plan and of intention to eat meals.
- B. Eat 50% of six small meals each day by the end of one week.
- C. Meals prepared during hospitalization will be fed by the nurse.
- D. Demonstrate progressive weight gain toward the ideal weight.
Correct Answer: B
Rationale: The correct short-term goal for the client with imbalanced nutrition is choice B: Eat 50% of six small meals each day by the end of one week. This goal is specific, measurable, achievable, relevant, and time-bound (SMART). By setting a goal for the client to eat a specific amount of meals within a defined timeframe, it allows for objective monitoring of progress. This goal also addresses the client's decreased intake and aims to improve their nutritional status gradually.
Choice A is incorrect as verbalizing understanding does not directly address the client's nutritional needs. Choice C is not appropriate as it does not promote independence in meal consumption. Choice D is not the best short-term goal as it focuses on the outcome of weight gain rather than the process of increasing food intake. Overall, choice B is the most appropriate short-term goal as it targets the client's specific nutritional needs and provides a clear direction for intervention.
assessment, the patient is restless, heart rate has increased to 110 beats/min, respirations are 36 breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sinaubsir bt.acocmh/ytecsat rdia with 10 premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretio ns. Loud crackles are audible throughout lung fields. The nurse notifies the physician, w ho orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. How d oes the nurse interpret the following blood gas levels? pH 7.28 PaCO 46 mm Hg Bicarbonate 22 mEq/L PaO 58 mm Hg O saturation 88% 2
- A. Hypoxemia and compensated respiratory alkalosis
- B. Hypoxemia and uncompensated respiratory acidosis
- C. Normal arterial blood gas levels
- D. Normal oxygen level and partially compensated metabaobliribc.c aomci/dteosts is
Correct Answer: B
Rationale: The correct answer is B: Hypoxemia and uncompensated respiratory acidosis.
Step-by-step rationale:
1. pH is low (7.28), indicating acidosis.
2. PaCO2 is elevated (46 mm Hg), indicating respiratory acidosis.
3. PaO2 is low (58 mm Hg), indicating hypoxemia.
4. Bicarbonate is within normal range (22 mEq/L), suggesting no compensation for the acidosis.
5. Oxygen saturation is low (88%), supporting the presence of hypoxemia.
Summary:
A: Incorrect - pH is low, not indicating compensated alkalosis.
C: Incorrect - Various abnormalities in the blood gas levels are present.
D: Incorrect - There is hypoxemia and uncompensated acidosis, not metabolic alkalosis.
When addressing an ethical dilemma, contextual, physiolo gical, and personal factors of the situation must be considered. Which of the following is an example of a personal factor?
- A. The hospital has a policy that everyone must have an aadbvirba.ncocme/dte sdt irective on the chart.
- B. The patient has lost 20 pounds in the past month and is fatigued all of time.
- C. The patient has expressed their beliefs concerning wha t quality of life means and their wishes.
- D. The primary care provider considers care to be futile in a given situation.
Correct Answer: C
Rationale: The correct answer is C because the patient's expressed beliefs and wishes regarding quality of life are personal factors that directly influence the ethical dilemma. This factor reflects the individual's values, beliefs, and preferences, which are essential in making ethical decisions that respect the patient's autonomy. Considering the patient's beliefs helps healthcare professionals navigate complex ethical situations by aligning the care provided with the patient's values. Choices A, B, and D do not directly relate to personal factors but rather focus on hospital policies, physiological symptoms, and the provider's perspective, respectively. Personal factors are crucial in ethical decision-making as they center on the patient's autonomy and preferences.
Acute kidney injury from postrenal etiology is caused by
- A. obstruction of the flow of urine.
- B. conditions that interfere with renal perfusion.
- C. hypovolemia or decreased cardiac output.
- D. conditions that act directly on functioning kidney tissue.
Correct Answer: A
Rationale: The correct answer is A because postrenal acute kidney injury is caused by obstruction of urine flow, leading to pressure build-up in the kidneys and subsequent damage. Obstructions can be due to conditions such as kidney stones, tumors, or enlarged prostate. Choices B, C, and D are incorrect as they relate to pre-renal and intrinsic renal causes of acute kidney injury, not specifically postrenal obstruction. B refers to decreased blood flow to the kidneys, C to low volume or poor heart function affecting kidney perfusion, and D to direct damage to kidney tissue, which do not characterize postrenal etiology.
Assuming each of these patients was discharged from the hospital, which older adult patient is at greatest risk for decreased functional status and quality of life?
- A. A 70-year-old who had coronary artery bypass surgery developed complications after surgery and had difficulty being weaned from meacbhirba.ncoicma/tle svt entilation. The patient required a tracheostomy and gastrostomy and is now being discharged to a long-term, acute care hospital. The patient lost their sig nificant other 3 years ago.
- B. A 79-year-old admitted for exacerbation of heart failure manages health care independently but needs diuretic medications adjusted . The patient states being compliant with prescribed medications but sometimes forgets to take them. The patient and 82-year-old spouse consider themselves to be independent and support each other.
- C. A 90-year-old admitted for a carotid endarterectomy lives in an assisted living facility (ALF) but is cognitively intact and claims to be the “social butterfly” at all of the events at the ALF. The patient is hospitalized for 4 days and discharged to the ALF.
- D. An 84-year-old who had stents placed to treat coronary artery occlusion has diabetes that has been managed, lives alone since losin g significant other 10 years ago, and was driving prior to hospitalization. The patieanbitr bw.caoms /dteisst charged home within 3 days of the procedure.
Correct Answer: A
Rationale: The correct answer is A because this patient had a complex surgery with complications, requiring long-term care and loss of a significant other, which can impact their emotional well-being and support system. This can lead to decreased functional status and quality of life.
Choice B is incorrect as the patient has support from a spouse and manages health care independently, indicating a good support system. Choice C is incorrect as the patient is cognitively intact and social, which suggests a good quality of life. Choice D is incorrect as the patient had a less complex procedure, well-managed diabetes, and was living independently, which indicates a lower risk for decreased functional status and quality of life compared to choice A.