Nokea
The patient is admitted to the unit with the diagnosis of rhabdomyolysis. The patient is started on intravenous (IV) fluids and IV mannitol. What action by the nurse is best?
- A. Assess the patient’s hearing.
- B. Assess the patient’s lungs.
- C. Decrease IV fluids once the diuretic has been administered.
- D. Give extra doses before giving radiological contrast agents.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient’s lungs. Rhabdomyolysis can lead to acute kidney injury due to myoglobin release from damaged muscle cells. IV fluids and mannitol are given to prevent kidney damage by promoting myoglobin excretion. Assessing the patient’s lungs is crucial to monitor for potential complications such as acute respiratory distress syndrome (ARDS) which can occur as a result of rhabdomyolysis. This assessment helps to ensure early detection and prompt intervention if respiratory issues arise.
Summary of Incorrect Choices:
A: Assess the patient’s hearing - This is not directly related to rhabdomyolysis or its treatment.
C: Decrease IV fluids once the diuretic has been administered - Decreasing IV fluids can exacerbate kidney injury in rhabdomyolysis.
D: Give extra doses before giving radiological contrast agents - Mannitol is not routinely given before radiological contrast agents in the context of rhabdomyolysis management.
You may also like to solve these questions
As part of the Synergy Model, the nurse has identified a patient characteristic of resiliency. What patient behavior demonstrates resiliency?
- A. Dysfunctional grieving behaviors after receiving bad news
- B. Developing a list of questions for the physician
- C. Denial of any possible negative outcomes for a procedure
- D. Assigning blame to others for undesired outcomes of illness
Correct Answer: B
Rationale: The correct answer is B because developing a list of questions for the physician shows active engagement in their healthcare, seeking information, and taking control of their situation, which are characteristics of resiliency. This behavior indicates the patient's willingness to understand and cope with their health condition. Choices A, C, and D are incorrect as they demonstrate maladaptive coping mechanisms such as dysfunctional grieving, denial, and blame assignment, which are not indicative of resiliency. Resiliency involves adaptability, problem-solving, and seeking support, which are better exemplified by choice B.
Which statement regarding ethical concepts is true?
- A. A living will is the same as a healthcare proxy.
- B. A signed donor card ensures that organ donation will o ccur in the event of brain death.
- C. A surrogate is a competent adult designated by a perso n to make healthcare decisions in the event the person is incapacitated.
- D. A persistent vegetative state is the same as brain deatha ibnir bm.cooms/tt esstt ates.
Correct Answer: C
Rationale: Rationale: Choice C is correct because a surrogate is indeed a competent adult designated to make healthcare decisions for an incapacitated person. This individual is typically chosen by the person themselves through a legal document like a healthcare proxy. This ensures that someone trusted can make important decisions when the person is unable to do so. Choices A, B, and D are incorrect because a living will and healthcare proxy serve different purposes, a signed donor card does not guarantee organ donation in the event of brain death (medical criteria are also required), and a persistent vegetative state is different from brain death (brain death implies irreversible cessation of brain function while a vegetative state involves some level of brain function).
Which of the following is (are) official journal(s) of the A merican Association of Critical-Care Nurses? (Select all that apply.)
- A. American Journal of Critical Care
- B. Critical Care Clinics of North America
- C. Critical Care Nurse
- D. Critical Care Nursing Quarterly
Correct Answer: A
Rationale: Step-by-step rationale:
1. The American Association of Critical-Care Nurses (AACN) publishes the American Journal of Critical Care (AJCC).
2. The AJCC is a peer-reviewed journal that covers critical care nursing practice, research, and education.
3. The content in AJCC aligns with AACN's mission and standards for critical care nursing.
4. Hence, AJCC is an official journal of AACN.
Summary of other choices:
- B: Critical Care Clinics of North America - Not an official journal of AACN.
- C: Critical Care Nurse - Not an official journal of AACN.
- D: Critical Care Nursing Quarterly - Not an official journal of AACN.
A patient in the ICU is recovering from open-heart surgery. The nurse enters his room and observes that his daughter is performing effleurage on his arms and talking in a low voice about an upcoming family vacation that is planned. The room is dimly lit, and she hears the constant beeping of his heart monitor. From the hall she hears the cries of a patient in pain. Which of the following are likely stressors for the patient? Select all that apply.
- A. His daughters conversation
- B. His daughters effleurage
- C. The beeping of the heart monitor
- D. The dim lighting of the room
Correct Answer: C
Rationale: The correct answer is C: The beeping of the heart monitor is a likely stressor for the patient recovering from open-heart surgery in the ICU. The constant beeping can cause anxiety and uncertainty about their health status. The daughter's conversation and effleurage are likely comforting and supportive for the patient, reducing stress. The dim lighting may create a calming environment, and the distant cries of a patient in pain may evoke empathy but may not directly stress the recovering patient. Therefore, the beeping of the heart monitor stands out as a stressor among the choices provided.
The nurse is caring for a patient with an admitting diagnosis of congestive failure. While attempting to obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and tachypneic. What is the best action by the nurse?
- A. Limit the patient’s supine position to no more than 10 seconds.
- B. Administer anxiety medications while recording the pressure.
- C. Encourage the patient to take slow deep breaths while asbuirpb.icnoem./ test
- D. Elevate the head of the bed 45 degrees while recording pressures.
Correct Answer: D
Rationale: The correct answer is D: Elevate the head of the bed 45 degrees while recording pressures.
Rationale:
1. Elevating the head of the bed will help improve the patient's breathing by reducing the pressure on the diaphragm.
2. This position will also help alleviate the patient's anxiety and tachypnea, promoting better oxygenation.
3. Recording pressures in this position will provide accurate data for monitoring the patient's condition.
Summary:
A: Limiting the supine position to 10 seconds does not address the underlying issues causing the patient's anxiety and tachypnea.
B: Administering anxiety medications without addressing the positioning issue may not effectively manage the patient's symptoms.
C: Encouraging the patient to take slow deep breaths is helpful, but changing the position of the patient is more crucial in this situation.