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The patient has been admitted to the hospital with nausea and vomiting that started 5 days earlier. Blood pressure is 80/44 mm Hg and heart rate is 122 beats/min; the patient has not voided in 8 hours, and the bladder is not distended. The nurse anticipates a prescription for “stat” administration of
- A. a blood transfusion.
- B. fluid replacement with 0.45% saline.
- C. infusion of an inotropic agent.
- D. an antiemetic.
Correct Answer: B
Rationale: The correct answer is B: fluid replacement with 0.45% saline. The patient's low blood pressure, tachycardia, and lack of urine output indicate hypovolemia. Fluid replacement with saline will help restore circulating volume, improve blood pressure, and support renal perfusion. A: Blood transfusion is not indicated as the primary issue is hypovolemia, not anemia. C: Inotropic agents are used to increase cardiac contractility but are not the initial treatment for hypovolemia. D: Antiemetics may help with symptoms but do not address the underlying issue of fluid loss and hypovolemia.
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A patient has just been admitted to the ICU after being in a severe auto accident and losing one of her legs. Her husband has his hand over his heart and complains of a rapid heart rate. The nurse recognizes his condition as a sign of which stage of the general adaptation syndrome to stress?
- A. Alarm stage
- B. Exhaustion stage
- C. Resistance stage
- D. Adaptation stage
Correct Answer: A
Rationale: The correct answer is A: Alarm stage. The husband's rapid heart rate indicates the initial alarm reaction to stress, characterized by physiological arousal. This stage involves the body's fight-or-flight response to a stressor. In this scenario, the husband is experiencing the physiological effects of the stressful situation, such as the auto accident and loss of a limb. The other choices are incorrect because:
B: Exhaustion stage occurs if stress continues without relief, leading to depletion of resources and increased vulnerability to illness.
C: Resistance stage is the body's attempt to adapt and cope with the stressor after the initial alarm reaction.
D: Adaptation stage is not a recognized stage in the general adaptation syndrome model.
Which of the following statements describes the core conc ept of the synergy model of practice?
- A. All nurses must be certified in order to have the synerg y model implemented.
- B. Family members must be included in daily interdisciplaibnirabr.cyo mro/teusnt ds.
- C. Nurses and physicians must work collaboratively and synergistically to influence care.
- D. Unique needs of patients and their families influence nursing competencies.
Correct Answer: D
Rationale: Rationale:
D is correct because the synergy model focuses on individualized care based on patients' unique needs. This model emphasizes tailoring nursing competencies to address these needs, promoting holistic care. A is incorrect as certification is not a requirement. B involves family inclusion but does not capture the core concept. C mentions collaboration but does not specifically address individualized care.
The nurse is caring for a mechanically ventilated patient an d is charting outside the patient’s room when the ventilator alarm sounds. What is the priorit y order for the nurse to complete these actions? (Put a comma and space between each answer choice.)
- A. Check quickly for possible causes of the alarm that can be fixed.
- B. After troubleshooting, connect back to mechanical venti lator and reassess patient.
- C. Go to patient’s bedside.
- D. Manually ventilate the patient while getting respiratory therapist.
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Going to the patient’s bedside is the priority as it allows the nurse to assess the patient's condition directly.
2. By being at the bedside, the nurse can quickly evaluate the patient's breathing, vital signs, and other indicators for immediate action.
3. Direct assessment enables timely intervention and avoids delays in addressing potential life-threatening situations.
4. Checking for possible causes of the alarm and reconnection to the ventilator can follow, but assessing the patient's immediate needs takes precedence.
In summary, choice C is correct because direct patient assessment is the fundamental step in responding to a ventilator alarm to ensure patient safety and timely intervention. Choices A, B, and D are incorrect as they focus on troubleshooting and technical aspects before directly assessing the patient's condition.
Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?
- A. The patient’s oxygen saturation is 93%.
- B. The patient was last suctioned 6 hours ago.
- C. The patient’s respiratory rate is 32 breaths/minute.
- D. The patient has occasional audible expiratory wheezes.
Correct Answer: C
Rationale: The correct answer is C because a respiratory rate of 32 breaths/minute indicates increased work of breathing, which could be due to secretions that need to be suctioned. High respiratory rate may suggest inadequate oxygenation and ventilation. Oxygen saturation of 93% (choice A) is within an acceptable range and does not necessarily indicate the need for suctioning. Time since last suctioning (choice B) should be considered but is not as immediate an indication as an increased respiratory rate. Occasional audible expiratory wheezes (choice D) may be indicative of other respiratory issues but do not directly indicate the need for suctioning.
The nurse is using presence to reduce the anxiety of a critically ill patient. What nursing behavior demonstrates an effective use of presence?
- A. Staying in the patients room to complete documentation
- B. Having a conversation in the patients room that excludes the patient
- C. Maintaining eye contact with the patient during explanations
- D. Focusing on specific nursing care tasks while in the patients room
Correct Answer: C
Rationale: The correct answer is C because maintaining eye contact with the patient during explanations is a non-verbal way to show attentiveness and empathy, which can help reduce the patient's anxiety. This behavior demonstrates active listening and engagement, making the patient feel heard and understood.
A: Staying in the patient's room to complete documentation is not an effective use of presence as it does not involve direct interaction with the patient.
B: Having a conversation in the patient's room that excludes the patient is also not an effective use of presence as it does not involve engaging with the patient.
D: Focusing on specific nursing care tasks while in the patient's room, although important, may not necessarily demonstrate presence in reducing the patient's anxiety.