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What is a minimally acceptable urine output for a patient weighing 75 kg?
- A. Less than 30 mL/hour
- B. 37 mL/hour
- C. 80 mL/hour
- D. 150 mL/hour
Correct Answer: C
Rationale: The correct answer is C (80 mL/hour) because the minimum acceptable urine output for a patient is approximately 0.5-1 mL/kg/hour. For a 75 kg patient, this equates to 37.5-75 mL/hour. Therefore, an output of 80 mL/hour is within this range and is considered minimally acceptable.
A: Less than 30 mL/hour is incorrect because it is below the recommended range for a 75 kg patient.
B: 37 mL/hour is close to the lower end of the acceptable range, but it is not the minimum acceptable output.
D: 150 mL/hour is above the recommended range and would be considered excessive for a 75 kg patient.
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The assessment of pain and anxiety is a continuous proces s. When critically ill patients exhibit signs of anxiety, what is the nurse’s first priority?
- A. To administer antianxiety medications as ordered
- B. To administer pain medication as ordered
- C. To identify and treat the underlying cause
- D. To reassess the patient hourly to determine whether symptoms resolve on their own
Correct Answer: C
Rationale: The correct answer is C: To identify and treat the underlying cause. The first priority of the nurse when critically ill patients exhibit signs of anxiety is to determine the root cause of the anxiety. By identifying and addressing the underlying cause, the nurse can effectively manage the patient's anxiety and prevent further complications. Administering medications without understanding the cause can mask the symptoms and lead to ineffective treatment. Reassessing the patient hourly may not address the root cause and could delay appropriate intervention. Pain medication may not be necessary if the anxiety is not related to pain. Treating the underlying cause ensures holistic and effective care for the patient.
The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?
- A. Grave's disease.
- B. Multiple sclerosis.
- C. Addison's disease.
- D. Cushing syndrome.
Correct Answer: A
Rationale: Step 1: Symptoms of weight loss, racing heart rate, and difficulty sleeping are common in hyperthyroidism.
Step 2: Presence of moist skin, fine hair, prominent eyes, lid retraction, and staring expression are classic signs of Grave's disease, a type of hyperthyroidism.
Step 3: Grave's disease is an autoimmune disorder where the thyroid gland is overactive, leading to excessive production of thyroid hormones.
Step 4: Excess thyroid hormones increase metabolic rate, causing weight loss, racing heart rate, and insomnia.
Step 5: Therefore, the findings described in the question are consistent with Grave's disease.
The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education?
- A. The RN increases the FIO2 to 100% before suctioning.
- B. The RN secures a bite block in place using adhesive tape.
- C. The RN asks for assistance to reposition the endotracheal tube.
- D. The RN positions the patient with the head of the bed at 10 degrees.
Correct Answer: D
Rationale: The correct answer is D because positioning the patient with the head of the bed at 10 degrees is incorrect for a patient receiving mechanical ventilation. The optimal position for such patients is to elevate the head of the bed to 30-45 degrees to prevent aspiration and improve oxygenation. Option A is incorrect as increasing FIO2 before suctioning is appropriate to ensure adequate oxygenation. Option B is incorrect as securing a bite block in place using adhesive tape is a standard practice to prevent the patient from biting on the endotracheal tube. Option C is incorrect as asking for assistance to reposition the endotracheal tube shows the RN is aware of the importance of proper placement to ensure effective ventilation.
What is the most important nursing intervention for patien ts who receive neuromuscular blocking agents?
- A. Administer sedatives in conjunction with the neuromu as bc iu rbl .a cor m b /tl eo sc t king agents.
- B. Assess neurological status every 30 minutes.
- C. Avoid interaction with the patient, because he or she won’t be able to hear.
- D. Restrain the patient to avoid self-extubation.
Correct Answer: B
Rationale: The correct answer is B: Assess neurological status every 30 minutes. This intervention is crucial for patients receiving neuromuscular blocking agents to monitor for any adverse effects such as respiratory depression or paralysis. Regular assessments help ensure early detection of complications and prompt intervention.
A: Administering sedatives in conjunction with neuromuscular blocking agents can potentiate respiratory depression and lead to respiratory compromise.
C: Avoiding interaction with the patient is not appropriate as communication and patient interaction are important aspects of nursing care.
D: Restraint should be avoided as it can increase the risk of complications such as pressure ulcers, anxiety, and decreased respiratory function.
Overall, regular neurological assessments are essential for ensuring patient safety and prompt intervention in case of any complications.
The nurse is caring for a patient who is orally intubated and on a mechanical ventilator. The nurse believes that the patient is experiencing excess anxiety. For this patient, what behavior best indicates anxiety?
- A. Restlessness
- B. Verbalization
- C. Increased respiratory rate
- D. Glasgow Coma Scale score of 3
Correct Answer: A
Rationale: The correct answer is A: Restlessness. Restlessness is a common behavioral indicator of anxiety in patients. In this scenario, a patient who is orally intubated and on a ventilator may not be able to verbally express anxiety, making restlessness a more prominent sign. Verbalization may not be possible due to intubation. While increased respiratory rate can be a symptom of anxiety, it is also a common physiological response in patients on mechanical ventilation. A Glasgow Coma Scale score of 3 indicates severe impairment of consciousness, not specifically anxiety.