Nokea
The patient is on intake and output (I&O), as well as daily weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should
- A. draw a trough level after the next dose of antibiotic.
- B. obtain an order to place the patient on fluid restriction.
- C. assess the patient’s lungs.
- D. insert an indwelling catheter.
Correct Answer: C
Rationale: First, the nurse should assess the patient's lungs to rule out any potential respiratory issues causing fluid retention. This is crucial as the patient has signs of fluid imbalance with decreased output and increased weight. Assessing the lungs can help identify conditions like heart failure or pneumonia that may contribute to these changes. Drawing a trough level (choice A) is not a priority as it doesn't address the immediate concern of fluid imbalance. Placing the patient on fluid restriction (choice B) should only be done after identifying the cause of the imbalance. Inserting an indwelling catheter (choice D) is not necessary at this point as the issue is related to fluid balance, not urinary elimination.
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The nurse caring for a patient with an endotracheal tube un derstands that endotracheal suctioning is needed to facilitate removal of secretions. What additional information is the nurse aware of concerning this intervention?
- A. It decreases intracranial pressure.
- B. It depresses the cough reflex.
- C. It is done as indicated by patient assessment.
- D. It is more effective if preceded by saline instillation to loosen secretions.
Correct Answer: C
Rationale: Rationale for Correct Answer C: Endotracheal suctioning should be done as indicated by patient assessment because not all patients require routine suctioning. Performing unnecessary suctioning can lead to potential complications such as mucosal damage and increased risk of infection. Therefore, the nurse must assess the patient's respiratory status, auscultate lung sounds, monitor oxygen saturation levels, and observe for signs of increased secretions before deciding to perform suctioning.
Summary of Incorrect Choices:
A: Endotracheal suctioning does not directly impact intracranial pressure. It is primarily focused on maintaining airway patency and removing respiratory secretions.
B: While endotracheal suctioning may temporarily suppress the cough reflex during the procedure, its primary purpose is to clear airway secretions to prevent complications such as atelectasis and respiratory distress.
D: Saline instillation before suctioning is not recommended as it can lead to negative outcomes such as dehydration, mucosal damage, and increased risk of infection
What is the main purpose of certification for critical care n ursing?
- A. To assure the consumer that critical nurses will not make a mistake.
- B. To help prepare the critical care nurse for graduate sch ool.
- C. To assist in promoting magnet status for a facility.
- D. To validate a nurse’s knowledge of critical care nursing
Correct Answer: D
Rationale: The correct answer is D: To validate a nurse’s knowledge of critical care nursing. Certification in critical care nursing validates a nurse's expertise and knowledge in this specialized area of nursing. It demonstrates that the nurse has met certain standards and competencies in critical care practice. This certification ensures that the nurse is well-equipped to provide high-quality care to critically ill patients.
A: To assure the consumer that critical nurses will not make a mistake - This choice is incorrect because certification does not guarantee that nurses will not make mistakes. It focuses on validating knowledge and skills rather than infallibility.
B: To help prepare the critical care nurse for graduate school - This choice is incorrect as certification is more focused on practice readiness rather than academic preparation.
C: To assist in promoting magnet status for a facility - This choice is incorrect as magnet status relates more to the overall excellence and quality of nursing care in a facility, not individual certification.
The nurse is caring for a patient who is mechanically ventilated. The nurse understands that what statement should be considered when determining apapbrirob.pcormia/ttees tn ursing interventions?
- A. Communication with intubated patients is often difficult.
- B. Controlled ventilation is the preferred mode for most p atients.
- C. Patients with chronic obstructive pulmonary disease w ean easily from mechanical ventilation.
- D. Wrist restraints are applied to all patients to avoid self- extubation.
Correct Answer: A
Rationale: The correct answer is A because communication with intubated patients is often challenging due to the presence of an artificial airway, which hinders speech. This understanding is crucial when determining appropriate nursing interventions to ensure effective patient care.
Choice B is incorrect because different patients may require different modes of ventilation based on their specific condition, and controlled ventilation may not always be the preferred mode for all patients.
Choice C is incorrect as patients with chronic obstructive pulmonary disease often have difficulty weaning from mechanical ventilation due to their underlying respiratory condition.
Choice D is incorrect as wrist restraints are not applied to all patients on mechanical ventilation unless absolutely necessary for safety concerns, such as preventing self-extubation.
A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT?
- A. New ST segment elevation is noted on the cardiac monitor.
- B. Enteral feedings are being given through an orogastric tube.
- C. Scattered rhonchi are heard when auscultating breath sounds.
- D. HYDROmorphone (Dilaudid) is being used to treat postoperative pain.
Correct Answer: A
Rationale: The correct answer is A: New ST segment elevation is noted on the cardiac monitor. This finding is concerning because it may indicate myocardial ischemia or infarction, which can be exacerbated by the physiological stress of weaning from mechanical ventilation. It is crucial to address any cardiac issues before initiating a spontaneous breathing trial to prevent potential cardiac complications during the weaning process.
Explanation for why the other choices are incorrect:
B: Enteral feedings being given through an orogastric tube are not contraindicated for starting a spontaneous breathing trial.
C: Scattered rhonchi heard when auscultating breath sounds may indicate retained secretions but are not a contraindication for a spontaneous breathing trial.
D: The use of HYDROmorphone to treat postoperative pain is not a contraindication for a spontaneous breathing trial unless it is causing respiratory depression, which would need to be addressed separately.
The nurse is caring for a patient receiving continuous norepinephrine (Levophed) IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted?
- A. Heart rate is 58 beats/minute.
- B. Mean arterial pressure (MAP) is 56 mm Hg.
- C. Systemic vascular resistance (SVR) is elevated.
- D. Pulmonary artery wedge pressure (PAWP) is low.
Correct Answer: B
Rationale: The correct answer is B because a low Mean Arterial Pressure (MAP) indicates inadequate perfusion, which may require adjusting the norepinephrine infusion rate to increase blood pressure. A: A heart rate of 58 beats/minute is within a normal range and may not necessarily indicate a need for adjustment. C: Elevated Systemic Vascular Resistance (SVR) may be an expected response to norepinephrine and does not necessarily indicate a need for adjustment. D: A low Pulmonary Artery Wedge Pressure (PAWP) may indicate fluid volume deficit but does not directly relate to the need for adjusting norepinephrine infusion rate.