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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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A PaCO 2 of 48 mm Hg is associated with what outcome?
- A. Hyperventilation
- B. Hypoventilation
- C. Increased absorption of O
- D. Increased excretion of HCO
Correct Answer: B
Rationale: The correct answer is B: Hypoventilation. A PaCO2 of 48 mm Hg indicates an elevated level of carbon dioxide in the blood, which is typically seen in hypoventilation where the lungs are not effectively removing CO2. Hypoventilation leads to respiratory acidosis. Option A is incorrect because hyperventilation would decrease PaCO2 levels. Option C is incorrect as it does not directly relate to PaCO2 levels. Option D is incorrect as increased excretion of HCO3- would not directly affect PaCO2 levels.
When providing palliative care, the nurse must keep in mind that the family may include which of the following? (Select all that apply.)
- A. Unmarried life partners of same sex
- B. Unmarried life partners of opposite sex
- C. Roommates
- D. Close friends
Correct Answer: A
Rationale: The correct answer is A: Unmarried life partners of same sex. When providing palliative care, it's crucial to recognize and respect diverse family structures. Unmarried life partners of the same sex may form a significant familial bond, requiring support and involvement in care decisions. This choice aligns with the principles of inclusivity and non-discrimination in palliative care.
Incorrect choices:
B: Unmarried life partners of the opposite sex - This choice is incorrect as it limits the definition of family to only opposite-sex partners, excluding same-sex couples.
C: Roommates - While roommates may provide support, they do not necessarily have the same level of emotional and decision-making involvement as family members or life partners.
D: Close friends - While close friends can be important sources of support, they do not necessarily have the same legal or emotional ties as a life partner.
Which intervention about visitation in the critical care unit is true?
- A. The majority of critical care nurses implement restricte d visiting hours to allow the patient to rest.
- B. Children should never be permitted to visit a critically ill family member.
- C. Visitation that is individualized to the needs of patients and family members is ideal.
- D. Visiting hours should always be unrestricted.
Correct Answer: C
Rationale: The correct answer is C because individualized visitation meets the unique needs of patients and family members, promoting holistic care and emotional support. Choice A is incorrect as strictly restricted visiting hours may hinder family involvement in care. Choice B is incorrect as children can provide comfort and support. Choice D is incorrect as unrestricted visiting may disrupt patient rest and care routines.
The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring for this patient, the nurse should
- A. apply a sterile gauze dressing to maintain sterility.
- B. replace the transparent dressing every 10 days to prevent manipulation.
- C. assess the catheter site for redness and/or swelling.
- D. use the catheter for drawing blood samples to reduce patient discomfort.
Correct Answer: C
Rationale: The correct answer is C because assessing the catheter site for redness and/or swelling is crucial for early detection of infection. Redness and swelling are common signs of infection at the catheter site, which requires prompt intervention. Applying a sterile gauze dressing (choice A) is not necessary for a temporary percutaneous dialysis catheter. Replacing the transparent dressing every 10 days (choice B) is not recommended as it can increase the risk of infection. Using the catheter for drawing blood samples (choice D) is not appropriate as it can introduce contaminants and increase the risk of infection. Regular assessment of the catheter site is essential for early detection and prevention of complications.
The family members of a critically ill, 90-year-old patient bring in a copy of the patient’s living will to the hospital, which identifies the patient’s wiasbhireb.sc orme/gteasrt ding health care. The nurse discusses the contents of the living will with the patient’s physician. This is an example of implementation of which of the AACN Standards of Pr ofessional Performance?
- A. Acquires and maintains current knowledge of practice
- B. Acts ethically on the behalf of the patient and family
- C. Considers factors related to safe patient care
- D. Uses clinical inquiry and integrates research findings i n practice
Correct Answer: C
Rationale: The correct answer is C: Considers factors related to safe patient care. The scenario involves the nurse discussing the patient's living will with the physician, which is essential for ensuring safe patient care by following the patient's preferences. This aligns with the AACN standard of considering factors related to safe patient care, as the nurse is actively involving all relevant parties in decision-making to provide care that is in line with the patient's wishes.
Explanation of why other choices are incorrect:
A: Acquires and maintains current knowledge of practice - While important, this choice does not directly relate to the scenario where the focus is on safe patient care through communication and collaboration.
B: Acts ethically on behalf of the patient and family - While ethics are important, the scenario is more about following the patient's wishes as outlined in the living will rather than making ethical decisions.
D: Uses clinical inquiry and integrates research findings in practice - While valuable in nursing practice, this choice does not directly apply to the scenario where