The patient undergoes a cardiac catheterization that requires the use of contrast dyes during the procedure. To detect signs of contrast-induced kidney injury, the nurse should
- A. not be concerned unless urine output decreases.
- B. evaluate the patient’s serum creatinine for up to 72 hours after the procedure.
- C. obtain an order for a renal ultrasound.
- D. evaluate the patient’s postvoid residual volume to detect intrarenal injury.
Correct Answer: B
Rationale: The correct answer is B because evaluating the patient's serum creatinine for up to 72 hours after the procedure is crucial in detecting contrast-induced kidney injury. An increase in serum creatinine levels indicates impaired kidney function due to the contrast dye. This monitoring allows for early detection and intervention to prevent further kidney damage.
Choice A is incorrect because a decrease in urine output is a late sign of kidney injury and may not be present in the early stages. Choice C is incorrect as a renal ultrasound is not typically used to detect contrast-induced kidney injury. Choice D is incorrect as postvoid residual volume assessment is not specific to detecting intrarenal injury related to contrast dye use.
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To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should:
- A. Inflate the cuff with a minimum of 10 mL of air.
- B. Inflate the cuff until the pilot balloon is firm on palpation.
- C. Inject air into the cuff until a manometer shows 15 mm Hg pressure.
- D. Inject air into the cuff until a slight leak is heard only at peak inflation.
Correct Answer: D
Rationale: The correct answer is D because inflating the cuff until a slight leak is heard only at peak inflation ensures it is adequately sealed but not overinflated, preventing complications like tracheal injury or pressure necrosis. Choice A lacks specificity and can lead to overinflation. Choice B may result in overinflation as the firmness of the balloon is subjective. Choice C relies on a specific pressure reading, which may vary based on factors like tube size and patient anatomy, potentially leading to under- or overinflation.
A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped?
- A. The patient’s heart rate is 97 beats/min.
- B. The patient’s oxygen saturation is 93%.
- C. The patient’s respiratory rate is 32 breaths/min.
- D. The patient’s spontaneous tidal volume is 450 mL.
Correct Answer: C
Rationale: The correct answer is C because a respiratory rate of 32 breaths/min indicates increased work of breathing, which could be a sign of respiratory distress. In a patient being weaned from mechanical ventilation, an elevated respiratory rate suggests that the patient may not be able to sustain adequate ventilation on their own. This warrants stopping the weaning protocol to prevent respiratory failure.
Choice A is incorrect because a heart rate of 97 beats/min is within normal range for an adult. Choice B is incorrect because an oxygen saturation of 93% is acceptable for a patient with COPD. Choice D is incorrect because a tidal volume of 450 mL is adequate for a patient weaning from mechanical ventilation.
Which of the following are accepted nonpharmacological approaches to managing pain and/or anxiety in critically ill patients? (Select all that apply.)
- A. Environmental manipulation
- B. Explanations of monitoring equipment
- C. Guided imagery
- D. Music therapy
Correct Answer: A
Rationale: Step 1: Environmental manipulation involves adjusting factors like lighting, noise levels, and room temperature to create a soothing environment, which can help reduce pain and anxiety.
Step 2: By controlling the physical surroundings, patients may feel more comfortable and relaxed, leading to improved pain management and reduced anxiety levels.
Step 3: Explanations of monitoring equipment and guided imagery are not directly related to environmental changes that can impact pain and anxiety.
Step 4: Music therapy, while beneficial for some patients, is not categorized as environmental manipulation.
Which patient should the nurse notify the organ procureme nt organization (OPO) to evaluate for possible organ donation?
- A. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram
- B. A 68-year-old male admitted with unstable atrial fibrillation who has suffered a stroke
- C. A 40-year-old brain-injured female with a history of ovabairrbi.acnom c/taenstc er and a Glasgow Coma Scale score of 7
- D. A 53-year-old diabetic male with a history of unstable angina status post resuscitation
Correct Answer: A
Rationale: The correct answer is A because the patient is a 36-year-old with a Glasgow Coma Scale score of 3 and no activity on electroencephalogram, indicating severe brain injury and likely irreversible neurological damage. This patient meets the criteria for potential organ donation as they are neurologically devastated.
Choice B is incorrect because the patient's condition is related to stroke and atrial fibrillation, not severe brain injury that would make them a candidate for organ donation.
Choice C is incorrect because although the patient has a brain injury and a lower Glasgow Coma Scale score, the history of a reversible cause (ovarian cancer metastasis) and a higher GCS score compared to choice A make this patient less suitable for organ donation evaluation.
Choice D is incorrect as the patient's diabetic and cardiovascular history does not suggest severe brain injury that would qualify for organ donation.
When caring for a patient who has an arterial catheter in the left radial artery for arterial pressure-based cardiac output (APCO) monitoring, which information obtained by the nurse is most important to report to the health care provider?
- A. The patient has a positive Allen test.
- B. There is redness at the catheter insertion site.
- C. The mean arterial pressure (MAP) is 86 mm Hg.
- D. The dicrotic notch is visible in the arterial waveform.
Correct Answer: B
Rationale: The correct answer is B: There is redness at the catheter insertion site. Redness at the catheter insertion site could indicate infection, which is a serious complication that requires immediate attention to prevent sepsis. Reporting this to the healthcare provider promptly is crucial for timely intervention. Choices A, C, and D are not as urgent. A positive Allen test (choice A) assesses collateral circulation and is important for assessing perfusion before arterial cannulation but does not require immediate intervention. Choice C (MAP is 86 mm Hg) falls within the normal range, so it does not indicate an urgent issue. The visibility of the dicrotic notch in the arterial waveform (choice D) is a normal finding and does not require immediate action.