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The patient is in a progressive care unit following arteriovenous fistula implantation in his left upper arm, and is due to have blood drawn with his next set of vital signs and assessment. When the nurse assesses the patient, the nurse should
- A. draw blood from the left arm.
- B. take blood pressures from the left arm.
- C. start a new intravenous line in the left lower arm.
- D. auscultate the left arm for a bruit and palpate for a thrill.
Correct Answer: D
Rationale: The correct answer is D because after arteriovenous fistula implantation, it is essential to assess for the presence of a bruit (audible sound caused by turbulent blood flow) and thrill (vibratory sensation) in the access site, which indicates proper functioning of the fistula. This assessment ensures that blood is flowing adequately through the newly created access for dialysis or other procedures. Drawing blood or taking blood pressures from the fistula arm can lead to complications such as clot formation or damage to the fistula. Starting a new IV line in the same arm is contraindicated to avoid compromising the newly created fistula. Thus, auscultating for a bruit and palpating for a thrill are the appropriate nursing actions in this scenario.
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The intensive care unit (ICU) nurse educator will determine that teaching arterial pressure monitoring to staff nurses has been effective when the nurse:
- A. Balances and calibrates the monitoring equipment every 2 hours.
- B. Positions the zero-reference stopcock line level with the hemostatic axis.
- C. Ensures that the patient is supine with the head of the bed flat for all readings.
- D. Rechecks the location of the hemostatic axis when changing the patient’s position.
Correct Answer: B
Rationale: The correct answer is B because positioning the zero-reference stopcock line level with the hemostatic axis ensures accurate arterial pressure monitoring. Placing the stopcock at the hemostatic axis allows for correct measurement of blood pressure without any errors due to height differences. This positioning helps in obtaining precise and reliable readings.
A: Balancing and calibrating the monitoring equipment every 2 hours is important for equipment maintenance but does not directly impact the accuracy of arterial pressure monitoring.
C: Ensuring the patient is supine with the head of the bed flat is a standard position for arterial pressure monitoring but does not specifically address the correct positioning of the stopcock.
D: Rechecking the location of the hemostatic axis when changing the patient's position is essential for maintaining accuracy, but it does not directly relate to the initial correct positioning of the stopcock.
The nurse is caring for 80-year-old patient who has been tr eated for gastrointestinal bleeding. The family has agreed to withhold or withdraw additional treatment. The patient has a written advance directive specifying requests. The directive notes that the patient wants food and fluid to be continued and to be made physically comfortable. Th e nurse anticipates that several orders may be written to comply with this request, including which of the following? (Select all that apply.)
- A. “Do not resuscitate.”
- B. Change antibiotic to a less expensive medication.
- C. Discontinue tube feeding.
- D. Stop any further blood transfusions.
Correct Answer: A
Rationale: The correct answer is A: "Do not resuscitate." In this scenario, the patient's advance directive specifies a desire for comfort measures and continuation of food and fluids. A DNR order aligns with this directive by respecting the patient's wish to avoid aggressive life-saving measures. This choice prioritizes the patient's autonomy and quality of life. Other options (B, C, D) are not aligned with the patient's wishes. Changing antibiotics or stopping blood transfusions may be unrelated to the patient's comfort or food/fluid preferences. Discontinuing tube feeding goes against the directive's request for food and fluid continuation.
A family member tells the nurse, 'I don’t know how I’m going to manage without my mother. She took care of everything for us.' Which response by the nurse is most appropriate?
- A. You will learn how to manage things gradually, and I can provide some resources to help you.
- B. It will be difficult at first, but time will help you adjust to her loss.
- C. Perhaps another family member can take over the responsibilities your mother managed.
- D. It sounds like you will need to seek professional counseling to cope with this loss.
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the family member's feelings while offering support and resources for managing the situation gradually. By providing resources, the nurse empowers the family member to learn how to handle things independently over time. This approach promotes self-reliance and resilience.
Choice B focuses on time rather than active coping strategies, which may not address the family member's immediate needs. Choice C suggests shifting responsibilities to another family member without considering the emotional impact. Choice D jumps to the conclusion of needing professional counseling without exploring other potential solutions or support systems.
Intrapulmonary shunting refers to what outcome?
- A. Alveoli that are not perfused.
- B. Blood that is shunted from the left side of the heart to t he right and causes heart failure.
- C. Blood that is shunted from the right side of the heart to the left without oxygenation.
- D. Shunting of blood supply to only one lung.
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Intrapulmonary shunting refers to blood bypassing the normal oxygenation process in the lungs.
2. Choice C describes blood being shunted from the right side of the heart (deoxygenated blood) to the left side without oxygenation, leading to systemic circulation without oxygenation.
3. Choices A, B, and D do not accurately describe intrapulmonary shunting as they focus on other concepts like alveolar perfusion, heart failure, and unilateral lung blood supply, respectively.
A critically ill patient who is intubated and agitated is restrained with soft wrist restraints. Based on research findings, what is the best nursing action?
- A. Maintain the restraints to protect patient safety.
- B. Remove the restraints periodically to check skin integrity.
- C. Remove the restraints periodically for range of motion.
- D. Assess and intervene for causes of agitation. Answer Key
Correct Answer: D
Rationale: The correct answer is D: Assess and intervene for causes of agitation. In a critically ill patient, agitation while intubated could indicate underlying issues like pain, delirium, or inadequate sedation. By assessing and addressing the root cause of agitation, the nurse can improve patient comfort and prevent potential harm from restraints. Removing restraints periodically for skin integrity (B) and range of motion (C) is important but should not be the primary focus when agitation is present. Maintaining restraints (A) without addressing the agitation could lead to increased distress and potential complications.