Nokea
The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take?
- A. Withhold the medication and contact the healthcare provider.
- B. Give the medication dosage as scheduled.
- C. Assess respiratory rate for one minute next.
- D. Wait 30 minutes and give half of the dosage of medication.
Correct Answer: A
Rationale: The correct answer is A. Infants typically have higher resting heart rates than adults, so a pulse rate of 89 beats/minute for an infant may indicate bradycardia. Digoxin can further lower the heart rate, leading to potential adverse effects like arrhythmias. Therefore, withholding the medication and contacting the healthcare provider is crucial to ensure the safety of the infant.
Choice B is incorrect because administering digoxin without addressing the elevated pulse rate can be dangerous. Choice C is incorrect as assessing respiratory rate does not address the immediate concern of the elevated pulse rate. Choice D is also incorrect as waiting and giving half of the dosage may further exacerbate the situation.
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An Ethiopian man with AIDS has recently been admitted to the ICU with a case of pneumonia. The man is new to the U.S. and has no health insurance. He would likely be eligible for the states Medicaid coverage, but does not understand how to access this coverage. Which competency or competencies are most needed in this situation? Select all that apply.
- A. Clinical judgment
- B. Advocacy and moral agency
- C. Collaboration
- D. Systems thinking
Correct Answer: B
Rationale: The correct answer is B: Advocacy and moral agency. In this scenario, the Ethiopian man with AIDS is in a vulnerable position due to lack of health insurance and understanding of Medicaid coverage. Advocacy skills are crucial to help him navigate the complex healthcare system and access the necessary resources. Moral agency involves advocating for the patient's rights and well-being, ensuring that he receives appropriate care despite his socioeconomic status. Clinical judgment, collaboration, and systems thinking are important competencies but not as directly relevant in this specific situation of advocating for the patient's access to Medicaid coverage.
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.
Nociceptors differ from other nerve receptors in the body in what way?
- A. They adapt very little to continual pain response.
- B. They inhibit the infiltration of neutrophils and eosinophils.
- C. They play no role in the inflammatory response.
- D. They transmit only the thermal stimuli.
Correct Answer: A
Rationale: The correct answer is A because nociceptors are specialized nerve receptors that do not adapt much to continual pain response. This lack of adaptation allows nociceptors to continuously signal the presence of tissue-damaging stimuli, which is crucial for the perception of pain. Choices B, C, and D are incorrect because nociceptors do not inhibit the infiltration of neutrophils and eosinophils (B), they do play a role in the inflammatory response (C), and they transmit various types of stimuli including thermal, mechanical, and chemical, not just thermal stimuli (D).
When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)?
- A. Assist with endotracheal intubation.
- B. Insert an indwelling urinary catheter.
- C. Begin continuous cardiac monitoring.
- D. Obtain an order to restrain the patient.
Correct Answer: C
Rationale: Rationale:
Continuous cardiac monitoring is crucial during therapeutic hypothermia to monitor the patient's cardiac rhythm and detect any arrhythmias promptly. This intervention allows for immediate intervention if any cardiac issues arise.
Explanation of other choices:
A: Assisting with endotracheal intubation may be necessary for airway management but is not directly related to cooling the patient for therapeutic hypothermia.
B: Inserting an indwelling urinary catheter may be needed for urine output monitoring but is not a priority intervention for cooling the patient.
D: Restraining the patient is unnecessary and not indicated for therapeutic hypothermia; it may cause unnecessary distress and should be avoided unless absolutely necessary for patient safety.
The nurse recommends that the family of a critically ill patient seek help from the Critical Care Family Assistance Program. What benefit for the family does the nurse anticipate?
- A. Reduction of health care cost
- B. More physical comfort
- C. Multidisciplinary support
- D. Health promotion information
Correct Answer: C
Rationale: The correct answer is C: Multidisciplinary support. The Critical Care Family Assistance Program offers a range of professionals such as social workers, counselors, and financial advisors to provide holistic support to the family. This helps address emotional, financial, and practical needs during a challenging time. Option A is incorrect because the program does not directly reduce healthcare costs. Option B is incorrect as the focus is not solely on physical comfort but on comprehensive support. Option D is incorrect as the primary aim is not health promotion but rather addressing the family's immediate concerns and needs.