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To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to:
- A. Auscultate for the presence of bilateral breath sounds.
- B. Obtain a portable chest x-ray to check tube placement.
- C. Observe the chest for symmetric chest movement with ventilation.
- D. Use an end-tidal CO2 monitor to check for placement in the trachea.
Correct Answer: D
Rationale: The correct answer is D because using an end-tidal CO2 monitor is the most reliable method to confirm correct endotracheal tube placement in the trachea. This method detects exhaled CO2, indicating proper tube placement in the trachea. It is a quick and efficient way to confirm placement without delay, reducing the risk of complications.
A: Auscultating for bilateral breath sounds is not as reliable because breath sounds may be heard even if the tube is misplaced.
B: Obtaining a portable chest x-ray is not the best initial action as it takes time and delays confirming tube placement.
C: Observing chest movement may not provide conclusive evidence of proper tube placement and can lead to misinterpretation.
In summary, using an end-tidal CO2 monitor is the most accurate and efficient method to verify correct endotracheal tube placement compared to the other options.
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How should the nurse interprets these blood gas values? 2 3
- A. Compensated metabolic alkalosis
- B. Normal values
- C. Uncompensated respiratory acidosis
- D. Uncompensated respiratory alkalosis
Correct Answer: C
Rationale: The correct interpretation is uncompensated respiratory acidosis (Choice C) based on the values. Step 1: Evaluate pH - pH is <7.35, indicating acidosis. Step 2: Determine PaCO2 - PaCO2 is >45 mmHg, indicating respiratory cause. Step 3: Check HCO3- - HCO3- is within normal range, indicating uncompensated state. Choices A, B, and D are incorrect because they do not align with the given blood gas values.
The nurse cites evidence-based practice as a rationale for a patient care decision. What isthe best description of evidence-based practice?
- A. Decisions based on expert legal testimony
- B. Use of best available research data
- C. Evolution of nursing practice over time
- D. Individual optimization of patient outcomes
Correct Answer: B
Rationale: The correct answer is B: Use of best available research data. Evidence-based practice involves integrating the best available research evidence with clinical expertise and patient values to make informed decisions about patient care. It emphasizes using scientifically proven data to guide practice and improve patient outcomes. Expert legal testimony (A) is not necessarily evidence-based. Evolution of nursing practice over time (C) does not specifically focus on research data. Individual optimization of patient outcomes (D) is a goal of evidence-based practice, but it does not fully encompass the concept.
What term is used to describe a specific request made by a competent person that directs medical care related to life-prolonging procedures if the pa tient loses capacity to make decisions?
- A. Do not resuscitate order
- B. Healthcare proxy
- C. Informed consent
- D. Living will
Correct Answer: D
Rationale: The correct answer is D, Living will. A living will is a legal document that outlines a person's preferences for medical treatment if they become unable to communicate their wishes. It specifically addresses life-prolonging procedures. Option A, Do not resuscitate order, is a specific directive to not perform CPR in case of cardiac arrest, not a comprehensive medical care directive. Option B, Healthcare proxy, is a person designated to make medical decisions on behalf of a patient who is unable to do so, not the specific directive itself. Option C, Informed consent, refers to the process of obtaining permission from a patient before conducting a healthcare intervention, not a directive for life-prolonging procedures.
Which of the following is (are) official journal(s) of the A merican Association of Critical-Care Nurses? (Select all that apply.)
- A. American Journal of Critical Care
- B. Critical Care Clinics of North America
- C. Critical Care Nurse
- D. Critical Care Nursing Quarterly
Correct Answer: A
Rationale: Step-by-step rationale:
1. The American Association of Critical-Care Nurses (AACN) publishes the American Journal of Critical Care (AJCC).
2. The AJCC is a peer-reviewed journal that covers critical care nursing practice, research, and education.
3. The content in AJCC aligns with AACN's mission and standards for critical care nursing.
4. Hence, AJCC is an official journal of AACN.
Summary of other choices:
- B: Critical Care Clinics of North America - Not an official journal of AACN.
- C: Critical Care Nurse - Not an official journal of AACN.
- D: Critical Care Nursing Quarterly - Not an official journal of AACN.
The primary care provider orders the following mechanica l ventilation settings for a patient who weighs 75 kg and whose spontaneous respiratory rate is 22 breaths/min. What arterial blood gas abnormality may occur if the patient continues taob ibrbe.c otamc/thesyt pneic at these ventilator settings? Settings: Tidal volume: 600 mL (8 mL per kg) FiO 2: 0.5 Respiratory rate: 14 breaths/min Mode assist/control Positive end-expiratory pressure: 10 cm H O
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: C
Rationale: The correct answer is C: Respiratory acidosis may occur if the patient continues at these ventilator settings. Respiratory acidosis happens when the lungs cannot remove enough of the carbon dioxide (CO2) produced by the body. In this case, the low respiratory rate of 14 breaths/min may not be sufficient to adequately remove CO2, leading to its accumulation in the blood. This results in a decrease in blood pH, causing respiratory acidosis.
Summary of other choices:
A: Metabolic acidosis - Not the correct answer as the ventilator settings are more likely to affect the respiratory system rather than the metabolic system.
B: Metabolic alkalosis - Not the correct answer as the ventilator settings are not related to causing an increase in blood pH, which is characteristic of metabolic alkalosis.
D: Respiratory alkalosis - Not the correct answer as the low respiratory rate would not lead to excessive elimination of CO2, causing alkalosis.