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When assessing the patient for hypoxemia, the nurse recognizes what as an early sign of the effect of hypoxemia on the cardiovascular system?
- A. Heart block
- B. Restlessness
- C. Tachycardia
- D. Tachypnea
Correct Answer: C
Rationale: The correct answer is C: Tachycardia. Hypoxemia results in decreased oxygen levels in the blood, stimulating the body to increase heart rate to improve oxygen delivery. Tachycardia is an early sign of the cardiovascular system compensating for hypoxemia. Heart block (A) is a disruption in the electrical conduction within the heart and is not directly related to hypoxemia. Restlessness (B) is a non-specific sign and can be caused by various factors. Tachypnea (D) is an increased respiratory rate, which is a response to hypoxemia but not a direct effect on the cardiovascular system.
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The nurse is educating a patient’s family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates undaebrisrbt.acnomd/itnesgt of the purpose of the PAC?
- A. “The catheter will provide multiple sites to give intravenous fluid.”
- B. “The catheter will allow the primary health care provid er to better manage fluid therapy.”
- C. “The catheter tip comes to rest inside my brother’s pul monary artery.”
- D. “The catheter will be in position until the heart has a chance to heal.”
Correct Answer: B
Rationale: The correct answer is B because it shows understanding that the PAC helps in managing fluid therapy effectively. The PAC measures pressures in the heart and lungs, guiding fluid management. Choice A is incorrect as the PAC is not primarily for IV fluid administration. Choice C shows understanding of the catheter placement but not its purpose. Choice D is incorrect as the PAC is not for the heart to heal but to monitor cardiac status.
The nurse calculates the PaO /FiO ratio for the following values: PaO is 78 mm Hg; FiO is 2 2 2 2 6 (60%). What is the outcome and the relationship to the ARDS diagnosing criteria?
- A. 46.8; meets criteria for ARDS
- B. 130; meets criteria for ARDS
- C. 468; normal lung function
- D. Not enough data to compute the ratio
Correct Answer: A
Rationale: The correct answer is A: 46.8; meets criteria for ARDS. The PaO /FiO ratio is calculated by dividing the arterial oxygen partial pressure (PaO) by the fraction of inspired oxygen (FiO). In this case, PaO is 78 mm Hg and FiO is 0.6 (60%). Therefore, the calculation would be 78/0.6 = 130. This value is less than 300, which is indicative of ARDS according to the Berlin criteria. Choices B and C are incorrect as they do not align with the criteria for ARDS. Choice D is incorrect because the data provided is sufficient to compute the ratio.
A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam 1 to 2 mg IV as needed (prn). The patient has received no lorazepam during this course of illness. What is the most appropriate nursing intearbvirbe.ncotmio/tnes tt o control agitation?
- A. Administer fentanyl (Duragesic) 25 mg IV bolus.
- B. Administer midazolam 2 mg IV now.
- C. Increase the rate of the morphine infusion by 50%.
- D. Request an order for a paralytic agent.
Correct Answer: B
Rationale: Step-by-step rationale for why choice B is correct:
1. Midazolam is a benzodiazepine used for sedation and anxiolysis.
2. It acts quickly and has a short duration of action, suitable for acute agitation.
3. Lorazepam (also a benzodiazepine) is in the same drug class, ensuring compatibility.
4. Lorazepam is specifically ordered for this patient, indicating its appropriateness.
5. Administering midazolam addresses the patient's agitation efficiently and safely.
Summary of why other choices are incorrect:
A: Fentanyl is an opioid analgesic, not ideal for managing agitation.
C: Increasing morphine infusion can exacerbate sedation or respiratory depression.
D: Paralytic agents are used for neuromuscular blockade, not agitation control.
What is the focus of the synergy model of practice?
- A. Allowing unrestricted visiting for the patient 24 hours aebaircbh.c odma/tye.s t
- B. Providing holistic and alternative therapies.
- C. Considering the needs of patients and their families, w hich drives nursing competency.
- D. Addressing the patients’ needs for energy and support.
Correct Answer: C
Rationale: The correct answer is C because the synergy model of practice emphasizes considering the needs of patients and their families, which in turn drives nursing competency. This approach recognizes that patient care is not just about the individual but also about the broader support system. This holistic viewpoint helps nurses tailor their care to meet the unique needs of each patient and their family, ultimately leading to better outcomes.
Choices A, B, and D are incorrect:
A: Allowing unrestricted visiting for the patient 24 hours is not directly related to the focus of the synergy model which is more about patient-centered care.
B: Providing holistic and alternative therapies is a valid approach, but it is not the primary focus of the synergy model.
D: Addressing the patients' needs for energy and support is important but does not capture the comprehensive nature of the synergy model which encompasses the needs of both patients and their families.
The nurse is counseling a family about end-of-life care for their loved one. Which statement by the family indicates understanding of palliative care?
- A. Palliative care focuses on providing relief from pain and other symptoms.
- B. The goal of palliative care is to cure the patient’s disease.
- C. Palliative care is only provided during the final days of life.
- D. We will need to stop all treatments once palliative care begins.
Correct Answer: A
Rationale: The correct answer is A because palliative care indeed focuses on providing relief from pain and other symptoms, enhancing quality of life for patients with serious illnesses. This aligns with the essence of palliative care, which is to provide holistic support to improve comfort and well-being. The other choices are incorrect: B is wrong because palliative care does not aim to cure the underlying disease but rather to alleviate suffering; C is incorrect as palliative care can be initiated earlier in the disease trajectory, not just during the final days; and D is inaccurate because patients can continue receiving treatments alongside palliative care to manage symptoms and improve their quality of life.