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When caring for a patient with a pulmonary artery (PA) pressure catheter, the nurse observes that the PA waveform indicates that the catheter is in the wedged position. Which action should the nurse take next?
- A. Zero balance the transducer.
- B. Activate the fast flush system.
- C. Notify the health care provider.
- D. Deflate and reinflate the PA balloon.
Correct Answer: C
Rationale: The correct answer is C: Notify the health care provider. When the PA waveform indicates the catheter is in the wedged position, it means the catheter tip is in the pulmonary artery, potentially causing complications. The nurse should notify the healthcare provider immediately to assess and reposition the catheter to prevent further issues. Zero balancing the transducer (A) or activating the fast flush system (B) are not appropriate actions for this situation. Deflating and reinflating the PA balloon (D) could exacerbate the issue and should only be done under the guidance of the healthcare provider.
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The amount of effort needed to maintain a given level of ventilation is referred to using what term?
- A. Compliance
- B. Resistance
- C. Tidal volume
- D. Work of breathing
Correct Answer: D
Rationale: The correct answer is D: Work of breathing. Work of breathing refers to the amount of effort required to maintain a specific level of ventilation. This includes the energy needed for inhalation and exhalation. Compliance (A) refers to the ease with which the lungs expand, resistance (B) is the opposition to airflow in the airways, and tidal volume (C) is the amount of air moved in and out of the lungs during normal breathing. Work of breathing encompasses the overall energy expenditure involved in the breathing process, making it the most appropriate term in this context.
Which action by the nurse demonstrates cultural sensitivity in end-of-life care?
- A. Ensuring all patients receive the same standardized care.
- B. Avoiding discussions about death to prevent discomfort.
- C. Inquiring about specific cultural rituals and preferences.
- D. Advising families to follow hospital guidelines strictly.
Correct Answer: C
Rationale: The correct answer is C because inquiring about specific cultural rituals and preferences shows respect for the patient's cultural beliefs and values. By asking about these aspects, the nurse can provide care that aligns with the patient's cultural background, promoting comfort and understanding. This action also demonstrates a commitment to individualized care.
Choice A is incorrect because standardized care may not always be culturally appropriate. Choice B is incorrect as avoiding discussions about death can hinder effective communication and support. Choice D is incorrect as advising families to strictly follow hospital guidelines may overlook the importance of cultural considerations in end-of-life care.
When fluid is present in the alveoli what is the result?
- A. Alveoli collapse and atelectasis occurs.
- B. Diffusion of oxygen and carbon dioxide is impaired.
- C. Hypoventilation occurs.
- D. The patient is in heart failure.
Correct Answer: A
Rationale: The correct answer is A: Alveoli collapse and atelectasis occurs. When fluid is present in the alveoli, it impairs the surface tension necessary for the alveoli to remain open, leading to collapse and atelectasis. This prevents proper gas exchange, resulting in hypoxemia. Choice B is incorrect because impaired gas diffusion typically occurs with conditions affecting the alveolar-capillary membrane, not fluid in the alveoli. Choice C is incorrect as hypoventilation refers to decreased ventilation, not specifically related to fluid in the alveoli. Choice D is incorrect as fluid in the alveoli is not a direct indicator of heart failure.
A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action should the nurse include in the plan of care?
- A. Administer prescribed sedatives or opioids at bedtime to promote sleep.
- B. Cluster nursing activities so that the patient has uninterrupted rest periods.
- C. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps.
- D. Eliminate assessments between 0100 and 0600 to allow uninterrupted sleep.
Correct Answer: B
Rationale: The correct answer is B: Cluster nursing activities so that the patient has uninterrupted rest periods.
Rationale:
1. Clustering nursing activities allows for uninterrupted rest periods, essential for improving sleep quality and addressing disturbed sensory perception.
2. Administering sedatives or opioids (Option A) can lead to drug dependence, tolerance, and adverse effects in older adults.
3. Silencing alarms (Option C) compromises patient safety by impeding timely monitoring and response to critical events.
4. Eliminating assessments (Option D) between 0100 and 0600 disregards the necessity of monitoring vital signs and assessing patient condition around the clock.
The nurse is caring for a patient who has sustained blunt trauma to the left flank area, and is evaluating the patient’s urinalysis results. The nurse should become concerned when
- A. creatinine levels in the urine are similar to blood levels of creatinine.
- B. sodium and chloride are found in the urine.
- C. urine uric acid levels have the same values as serum levels.
- D. red blood cells and albumin are found in the urine.
Correct Answer: D
Rationale: The correct answer is D because the presence of red blood cells and albumin in the urine indicates possible kidney damage from the blunt trauma. This is concerning as it may suggest renal injury or dysfunction.
A: Creatinine levels in the urine being similar to blood levels is normal as creatinine is filtered by the kidneys.
B: Sodium and chloride being present in the urine is expected as they are components of urine.
C: Urine uric acid levels matching serum levels is common as uric acid is excreted by the kidneys.
In summary, the presence of red blood cells and albumin in the urine is abnormal and indicates potential kidney damage, making it the correct answer.