Nokea
The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis?
- A. Glasgow Coma Scale score of 3
- B. Train-of-four yields two twitches
- C. Bispectral index of 60
- D. CAM-ICU positive
Correct Answer: B
Rationale: The correct answer is B: Train-of-four yields two twitches. This assessment indicates a target level of paralysis because a train-of-four ratio of 2 twitches out of 4 suggests a 50% neuromuscular blockade, which is often the goal for patients receiving paralysis for procedures or ventilation.
A: A Glasgow Coma Scale score of 3 assesses consciousness, not neuromuscular blockade.
C: A Bispectral index of 60 measures depth of anesthesia, not paralysis level.
D: CAM-ICU assesses delirium, not neuromuscular blockade.
You may also like to solve these questions
The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?
- A. Use tweezers to remove any remaining ticks.
- B. Check the vital signs, including temperature.
- C. Give doxycycline (Vibramycin) 100 mg orally.
- D. Obtain information about recent outdoor activities.
Correct Answer: A
Rationale: The correct answer is A: Use tweezers to remove any remaining ticks. The first step is to remove the tick to prevent further transmission of any potential pathogens. This is crucial in preventing tick-borne illnesses. Checking vital signs (B) can be done after the tick is removed. Administering doxycycline (C) should be based on guidelines and individual factors. Obtaining information about recent outdoor activities (D) is important but not the immediate priority.
Which treatment can be used to dissolve a thrombus that is lodged in the pulmonary artery?
- A. Aspirin
- B. Embolectomy
- C. Heparin
- D. Thrombolytics
Correct Answer: D
Rationale: The correct answer is D: Thrombolytics. Thrombolytics are medications that can dissolve blood clots, making them effective in treating a thrombus lodged in the pulmonary artery. They work by activating the body's natural clot-dissolving system. Aspirin (A) is an antiplatelet drug and may prevent further clot formation but cannot dissolve an existing thrombus. Embolectomy (B) is a surgical procedure to remove a clot and is invasive, usually reserved for cases where thrombolytics are contraindicated. Heparin (C) is an anticoagulant that prevents clot formation but does not dissolve existing clots like thrombolytics do.
A nurse is on a committee that is trying to reduce the occurrence of hospital-acquired infections in the ICU. Her role is to conduct research to find which interventions have been shown to be most effective in reducing these infections. She consults many different sources and finds conflicting information. Which of the following sources should she consider the most authoritative?
- A. AACN expert panel report
- B. A meta-analysis of randomized controlled trials in the American Journal of Nursing
- C. A systematic review of qualitative studies in the Journal of Advanced Nursing
- D. A single randomized controlled trial in the American Journal of Critical Care
Correct Answer: B
Rationale: The correct answer is B: A meta-analysis of randomized controlled trials in the American Journal of Nursing.
1. Meta-analyses provide a comprehensive overview of multiple studies, increasing the reliability of the findings.
2. Randomized controlled trials are considered the gold standard in research design for assessing intervention effectiveness.
3. The American Journal of Nursing is a reputable source in the field of nursing, ensuring the credibility of the study.
4. By synthesizing data from various trials, the meta-analysis can offer a more robust and generalizable conclusion compared to a single trial or qualitative studies.
Incorrect choices:
A: AACN expert panel report - Expert opinions may vary and lack the empirical evidence provided by research studies.
C: A systematic review of qualitative studies in the Journal of Advanced Nursing - Qualitative studies may provide valuable insights but may not offer concrete evidence on intervention effectiveness like quantitative studies.
D: A single randomized controlled trial in the American Journal of Critical Care - Single trials may not capture the full picture and
A Muslim patient has been admitted to the critical care unit with complications after childbirth. Based on the Synergy Model, which nurse would be the most inappropriate to assign to care for this patient?
- A. New graduate female nurse
- B. Most experienced female nurse
- C. New graduate male nurse
- D. Female nurse with postpartum experience
Correct Answer: C
Rationale: Step-by-step rationale:
1. The Synergy Model emphasizes matching nurse competencies with patient needs.
2. A male nurse may not be culturally appropriate for a Muslim female patient due to religious beliefs.
3. Gender segregation is important in Islamic culture, especially concerning intimate care.
4. Therefore, assigning a new graduate male nurse to care for a Muslim female patient in critical condition is the most inappropriate choice.
Summary:
- Choice A is incorrect because being a new graduate does not impact cultural competence.
- Choice B is incorrect as experience does not necessarily make a nurse the best fit for a specific patient.
- Choice D is incorrect as postpartum experience is relevant, but cultural considerations are more critical in this scenario.
Positive end-expiratory pressure (PEEP) is a mode of ventaiblairbto.croym /atessst istance that produces which of the following conditions
- A. Each time the patient initiates a breath, the ventilator d elivers a full preset tidal volume.
- B. For each spontaneous breath taken by the patient, the tidal volume is determined by the patient’s ability to generate negative pressure.
- C. The patient must have a respiratory drive, or no breaths will be delivered.
- D. There is pressure remaining in the lungs at the end of eaxbiprbi.rcaotmio/tens tt hat is measured in cm H O.
Correct Answer: D
Rationale: The correct answer is D because positive end-expiratory pressure (PEEP) is a mode of ventilation where pressure is maintained in the lungs at the end of expiration. This helps prevent alveolar collapse and improves oxygenation. Option A is incorrect because PEEP does not deliver a full preset tidal volume with each breath initiation. Option B is incorrect because tidal volume in PEEP is not solely determined by the patient's ability to generate negative pressure. Option C is incorrect because in PEEP, breaths are delivered irrespective of the patient's respiratory drive.