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The patient is getting hemodialysis for the second time when he complains of a headache and nausea and, a little later, of becoming confused. The nurse realizes these are symptoms of
- A. dialyzer membrane incompatibility.
- B. a shift in potassium levels.
- C. dialysis disequilibrium syndrome.
- D. hypothermia.
Correct Answer: C
Rationale: The correct answer is C: dialysis disequilibrium syndrome. This occurs when there is a rapid decrease in urea concentration in the blood during hemodialysis, causing fluid shifts and cerebral edema leading to symptoms like headache, nausea, and confusion. Dialyzer membrane incompatibility (A) would present with allergic reactions, not neurological symptoms. A shift in potassium levels (B) may cause muscle weakness or cardiac arrhythmias, but not the described symptoms. Hypothermia (D) would present with low body temperature and shivering, not the neurological symptoms mentioned.
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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.
Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient’s arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3 of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to:
- A. Increase the FIO2.
- B. Increase the tidal volume.
- C. Increase the respiratory rate.
- D. Decrease the respiratory rate.
Correct Answer: D
Rationale: The correct answer is D: Decrease the respiratory rate. The ABG results show respiratory alkalosis with decreased PaCO2 and elevated pH. This indicates overventilation, so decreasing the respiratory rate will help normalize the PaCO2 and pH levels. Increasing the FIO2 (Choice A) is not needed as the PaO2 is within normal range. Increasing tidal volume (Choice B) can lead to further hyperventilation. Increasing the respiratory rate (Choice C) would exacerbate the respiratory alkalosis.
Family members are in the patient’s room when the patient has a cardiac arrest and the staff starts resuscitation measures. Which action should the nurse take next?
- A. Keep the family in the room and assign a staff member to explain the care given and answer questions.
- B. Ask the family to wait outside the patient’s room with a designated staff member to provide emotional support.
- C. Ask the family members whether they would prefer to remain in the patient’s room or wait outside the room.
- D. Tell the family members that patients are comforted by having family members present during resuscitation efforts.
Correct Answer: C
Rationale: The correct answer is C because it involves patient-centered care and respects the family's preferences. By asking the family members whether they would prefer to remain in the patient's room or wait outside, the nurse acknowledges their needs and allows them to make an informed decision based on their comfort level. This empowers the family members and promotes a supportive environment during a stressful situation.
Choice A is incorrect because it assumes that keeping the family in the room without their input is the best approach, which may not be the case for all families. Choice B is incorrect because asking the family to wait outside without considering their preferences may not be the most supportive action. Choice D is incorrect because it makes a blanket statement about patient comfort without considering individual family dynamics and preferences.
What diagnostic procedure is required to make a definitive diagnosis of pulmonary embolism?
- A. Arterial blood gas (ABG) analysis.
- B. Chest x-ray examination.
- C. High resolution multidetector CT angiogram.
- D. Ventilation-perfusion scanning.
Correct Answer: C
Rationale: The correct answer is C: High resolution multidetector CT angiogram. This diagnostic procedure is required for a definitive diagnosis of pulmonary embolism because it provides detailed imaging of the pulmonary vasculature, allowing visualization of blood clots in the pulmonary arteries.
A: Arterial blood gas (ABG) analysis does not directly diagnose pulmonary embolism but may show signs of hypoxemia or respiratory alkalosis, which can be seen in some cases of pulmonary embolism.
B: Chest x-ray examination may show nonspecific findings such as atelectasis or pleural effusion but cannot definitively diagnose pulmonary embolism.
D: Ventilation-perfusion scanning is another imaging modality used in the diagnosis of pulmonary embolism, but it is less commonly used compared to CT angiogram due to lower sensitivity and specificity.
The nurse is caring for a 48-year-old patient who is intubated and on a ventilator following extensive abdominal surgery. Although the patient is respo nsive, the nurse is not able to read the patient’s lips as the patient attempts to mouth the words. Which of the following assessment tools would be the most appropriate for the nu rse to use when assessing the patient’s pain level? (Select all that apply.)
- A. The FACES scale
- B. Pain Intensity Scale
- C. The PQRST method
- D. The Visual Analogue Scale
Correct Answer: A
Rationale: The correct answer is A: The FACES scale. This scale uses facial expressions to assess pain, making it suitable for a patient who is unable to verbalize. The nurse can show the patient a series of faces depicting varying levels of pain and ask them to point to the one that best represents their pain level. This method is non-verbal and easy for patients to understand.
The other choices are incorrect:
B: The Pain Intensity Scale requires the patient to rate their pain on a numerical scale, which may be difficult for a non-verbal patient.
C: The PQRST method is a mnemonic for assessing pain characteristics (provocation, quality, region, severity, timing), but it requires patient communication.
D: The Visual Analogue Scale involves marking a point on a line to indicate pain intensity, which is not suitable for a non-verbal patient.