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The patient is in the critical care unit and will receive dialysis this morning. The nurse will (Select all that apply.)
- A. evaluate morning laboratory results and report abnormal results.
- B. administer the patient’s antihypertensive medications.
- C. assess the dialysis access site and report abnormalities.
- D. weigh the patient to monitor fluid status.
Correct Answer: A
Rationale: The correct answer is A because evaluating morning lab results is crucial to monitor the patient's condition before dialysis. Abnormal results may impact the dialysis treatment plan. Option B is incorrect as administering antihypertensive medications is not directly related to dialysis. Option C is incorrect as assessing the dialysis access site is the responsibility of the dialysis team. Option D is incorrect as weighing the patient is not typically done immediately before dialysis.
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An intra-aortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met?
- A. Urine output of 25 mL/hr.
- B. Heart rate of 110 beats/minute.
- C. Cardiac output (CO) of 5 L/min.
- D. Stroke volume (SV) of 40 mL/beat.
Correct Answer: C
Rationale: The correct answer is C: Cardiac output (CO) of 5 L/min. In cardiogenic shock, the primary goal of using an IABP is to improve cardiac output to ensure adequate perfusion to vital organs. A cardiac output of 5 L/min indicates adequate blood flow and perfusion.
Choice A is incorrect as urine output is not a direct indicator of cardiac function. Choice B is incorrect as a heart rate of 110 beats/minute alone does not provide information on the effectiveness of the IABP in improving cardiac output. Choice D is incorrect as stroke volume alone does not provide a comprehensive assessment of overall cardiac function.
What nursing strategies help families cope with the stress of critical illness? (Select all that apply.)
- A. Asking the family to leave during the morning bath to promote the patient’s privacy.
- B. Encouraging family members to make notes of questio ns they have for the physician during family rounds.
- C. When possible, providing continuity of nursing care.
- D. Providing a daily update of the patient’s condition to the family spokesperson.
Correct Answer: B
Rationale: The correct answer is B: Encouraging family members to make notes of questions they have for the physician during family rounds. This strategy helps families cope with the stress of critical illness by empowering them to stay informed and actively participate in the patient's care. By encouraging them to make notes, it promotes effective communication with the healthcare team and ensures that their concerns and questions are addressed promptly.
Other choices are incorrect:
A: Asking the family to leave during the morning bath to promote the patient’s privacy is not a helpful strategy for coping with stress as it may lead to feelings of isolation and lack of involvement in the patient's care.
C: Providing continuity of nursing care is important but may not directly address the family's coping mechanisms during a critical illness.
D: Providing a daily update of the patient’s condition to the family spokesperson is valuable but may not fully address the family's need for active participation and communication with the healthcare team.
A 65-year-old patient admitted to the progressive care unit with a diagnosis of community-acquired pneumonia, has a history of chronic obstructive pulmonary disease and diabetes. A set of arterial blood gases obtained on admissiaobnir bw.coitmh/oteustt supplemental oxygen shows pH 7.35; PaCO 55 mm Hg; bicarbonate 30 mEq/L ; PaO 65 mm Hg. These blood 2 2 gases reflect what condition?
- A. Hypoxemia and compensated metabolic alkalosis.
- B. Hypoxemia and compensated respiratory acidosis.
- C. Normal oxygenation and partly compensated metaboli c alkalosis.
- D. Normal oxygenation and uncompensated respiratory acidosis.
Correct Answer: B
Rationale: The correct answer is B: Hypoxemia and compensated respiratory acidosis. The patient's pH is within normal range (7.35), indicating compensation. The elevated PaCO2 (55 mm Hg) indicates respiratory acidosis due to inadequate ventilation, likely from COPD. The low PaO2 (65 mm Hg) indicates hypoxemia, common in pneumonia. The normal bicarbonate level (30 mEq/L) suggests metabolic compensation for respiratory acidosis. Choice A is incorrect as there is no metabolic alkalosis present. Choice C is incorrect as the patient has hypoxemia. Choice D is incorrect as the patient is showing compensated respiratory acidosis, not uncompensated.
The nurse calculates the PaO /FiO ratio for the following values: PaO is 78 mm Hg; FiO is 2 2 2 2 6 (60%). What is the outcome and the relationship to the ARDS diagnosing criteria?
- A. 46.8; meets criteria for ARDS
- B. 130; meets criteria for ARDS
- C. 468; normal lung function
- D. Not enough data to compute the ratio
Correct Answer: A
Rationale: The correct answer is A: 46.8; meets criteria for ARDS. The PaO /FiO ratio is calculated by dividing the arterial oxygen partial pressure (PaO) by the fraction of inspired oxygen (FiO). In this case, PaO is 78 mm Hg and FiO is 0.6 (60%). Therefore, the calculation would be 78/0.6 = 130. This value is less than 300, which is indicative of ARDS according to the Berlin criteria. Choices B and C are incorrect as they do not align with the criteria for ARDS. Choice D is incorrect because the data provided is sufficient to compute the ratio.
A client with osteoarthritis is given a new prescription for a nonsteroidal anti-inflammatory drug (NSAID). The client asks the nurse, 'How is this medication different from the acetaminophen I have been taking?' Which information about the therapeutic action of NSAIDs should the nurse provide?
- A. Are less expensive.
- B. Provide anti-inflammatory response.
- C. Increase hepatotoxic side effects.
- D. Cause gastrointestinal bleeding.
Correct Answer: B
Rationale: The correct answer is B: Provide anti-inflammatory response. NSAIDs work by inhibiting the enzyme cyclooxygenase, thereby reducing inflammation, pain, and fever. This is different from acetaminophen, which primarily acts as a pain reliever and fever reducer but lacks significant anti-inflammatory properties.
Explanation of why other choices are incorrect:
A: Are less expensive - Cost is not related to the therapeutic action of NSAIDs.
C: Increase hepatotoxic side effects - While NSAIDs can have adverse effects on the liver, hepatotoxicity is not a primary therapeutic action of these drugs.
D: Cause gastrointestinal bleeding - While NSAIDs can increase the risk of gastrointestinal bleeding, this is a potential side effect rather than the primary therapeutic action.