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The son of a dying patient tells the nurse, 'Mother doesn’t respond anymore when I visit. I don’t think she knows that I am here.' Which response by the nurse is appropriate?
- A. You may need to cut back your visits, for now, to avoid overtiring your mother.
- B. Withdrawal may sometimes be a normal response when preparing to leave life.
- C. It will be important for you to stimulate your mother as she gets closer to dying.
- D. Many patients don’t know what is going on around them at the end of life.
Correct Answer: B
Rationale: The correct answer is B because withdrawal is a common psychological response in the dying process. The nurse should explain to the son that his mother's lack of response may be her way of preparing to leave life. This response validates the son's concerns while providing reassurance.
Choice A is incorrect because cutting back visits may not address the underlying issue of the mother's withdrawal. Choice C is incorrect because stimulating the mother may not be beneficial or appropriate in this situation. Choice D is incorrect because not all patients experience a lack of awareness at the end of life, and assuming so may not be helpful in this context.
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The nurse is caring for a mechanically ventilated patient following bilateral lung transplantation. When planning the care of this patient, what is the priority nursing intervention?
- A. Thirty-degree elevation of head of bed
- B. Endotracheal suctioning as needed
- C. Frequent side to side repositioning
- D. Sequential compression stockings
Correct Answer: A
Rationale: The correct answer is A: Thirty-degree elevation of the head of the bed. This is the priority nursing intervention for a mechanically ventilated patient following bilateral lung transplantation because it helps optimize ventilation-perfusion matching, reduces the risk of aspiration, and improves oxygenation. Elevating the head of the bed also decreases the risk of ventilator-associated pneumonia.
B: Endotracheal suctioning as needed is important but not the priority intervention in this case.
C: Frequent side to side repositioning is important for preventing pressure ulcers but is not the priority for a ventilated patient post-lung transplant.
D: Sequential compression stockings are used for preventing deep vein thrombosis, which is important but not the priority in this scenario.
Upon entering the room of a patient with a right radial arte rial line, the nurse assesses the waveform to be slightly dampened and notices blood to bea bbirabc.ckoemd/te ustp into the pressure tubing. What is the best action by the nurse?
- A. Check the inflation volume of the flush system pressur e bag.
- B. Disconnect the flush system from the arterial line catheter.
- C. Zero reference the transducer system at the phlebostati c axis. WWWWWW ..TTHHEENNUURRSSIINNGGMMAASSTTEERRYY..CCOOMM
- D. Reduce the number of stopcocks in the flush system tubing.
Correct Answer: B
Rationale: The correct answer is B: Disconnect the flush system from the arterial line catheter. This action is necessary to prevent air from entering the patient's bloodstream, which can lead to air embolism. By disconnecting the flush system, the nurse stops the flow of air and ensures patient safety. Checking the inflation volume of the pressurized bag (A) is not the immediate concern in this situation. Zero referencing the transducer system (C) is unrelated to the issue of air entering the arterial line. Reducing the number of stopcocks in the flush system tubing (D) does not address the immediate risk of air embolism.
A patient’s status deteriorates and mechanical ventilation i s now required. The pulmonologist wants the patient to receive 10 breaths/min from the ventilaabtirobr.c bomu/tt ewst ants to encourage the patient to breathe spontaneously in between the mechanical breaths at his own tidal volume. This mode of ventilation is referred to by what term?
- A. Assist/control ventilation
- B. Controlled ventilation
- C. Intermittent mandatory ventilation
- D. Positive end-expiratory pressure
Correct Answer: C
Rationale: Rationale:
1. Intermittent Mandatory Ventilation (IMV) allows the patient to breathe spontaneously between the preset mechanical breaths.
2. It provides a set number of breaths per minute while allowing the patient to initiate additional breaths at their own tidal volume.
3. IMV is a partial ventilatory support mode, providing a balance between controlled and spontaneous breathing.
4. Assist/Control Ventilation (A) provides full support with every breath initiated by the patient or the ventilator.
5. Controlled Ventilation (B) does not allow for spontaneous breaths by the patient.
6. Positive End-Expiratory Pressure (D) is a separate mode focusing on maintaining positive pressure at the end of expiration, not providing breaths.
The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient’s urine output has been less than 20 mL/hour for the past 2 hours. The patient’s blood pressure is 100/60 mm Hg, and the pulse is 110 beats/min. Previously, the pulse was 90 beats/min with a blood pressure of 120/80 mm Hg. The nurse should
- A. contact the provider and expect a prescription for a normal saline bolus.
- B. wait until the provider makes rounds to report the assessment findings.
- C. continue to evaluate urine output for 2 more hours.
- D. ignore the urine output, as this is most likely postrenal in origin.
Correct Answer: A
Rationale: The correct answer is A: contact the provider and expect a prescription for a normal saline bolus. The patient is showing signs of hypovolemia with decreased urine output, low blood pressure, and elevated heart rate. This indicates inadequate perfusion and potential hypovolemic shock. Administering a normal saline bolus will help restore intravascular volume and improve perfusion. Waiting for the provider to make rounds (option B) could delay necessary intervention. Continuing to evaluate urine output for 2 more hours (option C) is not appropriate given the patient's current condition. Ignoring the urine output (option D) is dangerous as it could lead to further complications.
A nurse is the only one in the ICU who has not achieved certification in critical care nursing. She often will ask her fellow nurses what to do in caring for a patient because she doubts the accuracy of her knowledge and her intuition. She loves her work but wishes she could do it with a greater level of competence. What is the most important effect that obtaining certification would likely have on the nurses practice?
- A. Recognition by peers
- B. Increase in salary and rank
- C. More flexibility in seeking employment
- D. Increased confidence in making decisions
Correct Answer: D
Rationale: The correct answer is D: Increased confidence in making decisions. Obtaining certification in critical care nursing would likely enhance the nurse's knowledge and skills, leading to increased confidence in making clinical decisions. This confidence would stem from the rigorous training and education required to achieve certification, as well as the validation of her expertise in critical care nursing. With increased confidence, the nurse would be more self-assured in her abilities, leading to improved patient care outcomes.
Choice A: Recognition by peers is not the most important effect because while recognition is a positive outcome, it may not directly impact the nurse's ability to provide better patient care.
Choice B: Increase in salary and rank is not the most important effect because while financial benefits are important, the primary focus of obtaining certification should be on improving competence and patient care.
Choice C: More flexibility in seeking employment is not the most important effect because while certification may open up more job opportunities, the main benefit should be on enhancing the nurse's skills and confidence in providing quality