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The patient is complaining of severe flank pain when he tries to urinate. His urinalysis shows sediment and crystals along with a few bacteria. Using this information along with the clinical picture, the nurse realizes that the patient’s condition is
- A. prerenal.
- B. postrenal.
- C. intrarenal.
- D. not renal related.
Correct Answer: C
Rationale: The correct answer is C: intrarenal. The presence of sediment, crystals, and bacteria in the urinalysis indicates an issue originating within the kidney itself. This suggests a problem like a urinary tract infection or kidney stone causing the severe flank pain. Prerenal and postrenal conditions usually involve issues outside the kidney such as dehydration or urinary tract obstruction, which are not supported by the urinalysis findings. Choice D, not renal related, is incorrect as the symptoms and urinalysis results clearly point towards a renal issue.
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The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 12 5 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO ) of 90% on a 50% venturi mask. 2 Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pres sure (PAOP) of 3 mm Hg. The nurse questions which of the following primary health care provider’s order?
- A. Titrate supplemental oxygen to achieve a SpO > 94%a. birb.com/test
- B. Infuse 500 mL 0.9% normal saline over 1 hour.
- C. Obtain arterial blood gas and serum electrolytes.
- D. Administer furosemide 20 mg intravenously.
Correct Answer: D
Rationale: The correct answer is D: Administer furosemide 20 mg intravenously. In this scenario, the patient is hypotensive with a low cardiac output, low CVP, and low PAOP, indicating cardiogenic shock. Administering furosemide, a diuretic, can worsen the patient's condition by further decreasing preload. This can lead to a decrease in cardiac output and exacerbate the shock state. The other options are more appropriate:
A: Titrate supplemental oxygen to achieve a SpO > 94% - Correct, as improving oxygenation is essential in cardiogenic shock.
B: Infuse 500 mL 0.9% normal saline over 1 hour - Correct, as fluid resuscitation may be necessary to improve perfusion.
C: Obtain arterial blood gas and serum electrolytes - Correct, as these tests provide valuable information about the patient's oxygenation and electrolyte balance.
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.
Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict?
- A. Require the UAPs to reach a compromise.
- B. Weigh the consequences of each possible solution.
- C. Encourage the two to view the humor of the conflict.
- D. Deal with issues and not personalities.
Correct Answer: D
Rationale: The correct answer is D: Deal with issues and not personalities. This guideline is important because it focuses on resolving the conflict based on the actual problem at hand, rather than personal biases or emotions. By addressing the issues causing the argument, the nurse can help the UAPs find a fair and logical solution.
A: Requiring the UAPs to reach a compromise may not address the root cause of the conflict and could lead to further disagreements.
B: Weighing the consequences is important but may not be as effective in resolving the conflict as directly addressing the issues.
C: Encouraging humor may temporarily diffuse the situation but may not lead to a lasting resolution.
Sleep often is disrupted for critically ill patients. Which nu rsing intervention is most appropriate to promote sleep and rest?
- A. Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals.
- B. Encourage family members to talk with the patient wh enever they are present in the room.
- C. Keep the television on to provide “white” noise and di straction.
- D. Leave the lights on in the room so that the patient is no t frightened of his or her surroundings.
Correct Answer: A
Rationale: The correct answer is A: Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals. This is the most appropriate intervention as medication timings can significantly impact sleep patterns of critically ill patients. Adjusting medication times can help synchronize rest periods, promoting uninterrupted sleep.
Choice B is incorrect as encouraging constant conversation can disrupt sleep. Choice C is incorrect as the television noise can be stimulating and hinder rest. Choice D is incorrect as leaving the lights on can disrupt the patient's circadian rhythm and negatively impact sleep quality.
When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most important information for the nurse to obtain is:
- A. Central venous pressure (CVP).
- B. Systemic vascular resistance (SVR).
- C. Pulmonary vascular resistance (PVR).
- D. Pulmonary artery wedge pressure (PAWP).
Correct Answer: D
Rationale: The correct answer is D: Pulmonary artery wedge pressure (PAWP). This is crucial in monitoring a patient with a large anterior wall myocardial infarction as it provides information on left ventricular function and fluid status. A high PAWP may indicate left ventricular failure or fluid overload, requiring immediate intervention.
A: Central venous pressure (CVP) is not as specific for assessing left ventricular function and may not provide accurate information in this scenario.
B: Systemic vascular resistance (SVR) is important in assessing systemic blood flow, but it may not directly indicate left ventricular function in this case.
C: Pulmonary vascular resistance (PVR) is more relevant in conditions affecting the pulmonary circulation and may not be as immediately informative in assessing left ventricular function in this context.