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When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)?
- A. Assist with endotracheal intubation.
- B. Insert an indwelling urinary catheter.
- C. Begin continuous cardiac monitoring.
- D. Obtain an order to restrain the patient.
Correct Answer: C
Rationale: Rationale:
Continuous cardiac monitoring is crucial during therapeutic hypothermia to monitor the patient's cardiac rhythm and detect any arrhythmias promptly. This intervention allows for immediate intervention if any cardiac issues arise.
Explanation of other choices:
A: Assisting with endotracheal intubation may be necessary for airway management but is not directly related to cooling the patient for therapeutic hypothermia.
B: Inserting an indwelling urinary catheter may be needed for urine output monitoring but is not a priority intervention for cooling the patient.
D: Restraining the patient is unnecessary and not indicated for therapeutic hypothermia; it may cause unnecessary distress and should be avoided unless absolutely necessary for patient safety.
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The nurse is preparing to obtain a right atrial pressure (RA P/CVP) reading. What are the most appropriate nursing actions? (Select all that apply.)
- A. Compare measured pressures with other physiological parameters.
- B. Flush the central venous catheter with 20 mL of sterile saline.
- C. Inflate the balloon with 3 mL of air and record the pres sure tracing.
- D. Obtain the right atrial pressure measurement during en d exhalation.
Correct Answer: A
Rationale: The correct answer is A because comparing measured pressures with other physiological parameters ensures accuracy and consistency. This step helps in interpreting the RA P/CVP reading correctly. Choice B is incorrect as flushing the catheter with saline is not necessary for obtaining the pressure reading. Choice C is incorrect as inflating the balloon with air is not part of the correct procedure. Choice D is incorrect because obtaining the measurement during exhalation can affect the accuracy of the reading.
The nurse is caring for a patient who sustained a head injury and is unresponsive to painful stimuli. Which intervention is most appropriate while bathaibnirgb. ctohme/ tpesatt ient?
- A. Ask a family member to help you bathe the patient, and discuss the family structure with the family member during the procedure .
- B. Because the patient is unconscious, complete care as q uickly and quietly as possible.
- C. Inform the patient of the day and time, and what kind o f care you are providing.
- D. Turn the television on to the evening news so that you and the patient can be updated to current events.
Correct Answer: B
Rationale: The correct answer is B: Because the patient is unconscious, complete care as quickly and quietly as possible. This is the most appropriate intervention as it prioritizes the patient's comfort and minimizes unnecessary stimulation. Performing care quickly reduces the time the patient is exposed to potentially uncomfortable procedures. Being quiet also helps create a calming environment for the patient, which is important for someone who is unresponsive.
Explanation for other choices:
A: Asking a family member to help and discussing family structure is not appropriate as it can be intrusive and may not be relevant or beneficial to the patient's care.
C: Informing the patient of the day and time is unnecessary as the patient is unresponsive. Providing care is more crucial than updating the patient.
D: Turning on the television is inappropriate as it introduces unnecessary noise and distraction, which can be overwhelming for an unresponsive patient.
A patient declared brain dead is an organ donor. The following events occur: 1300 Diagnostic tests for brain death are completed. 1330 primary care provider reviews diagnostic test results and writes in the progress note that the patient is brain deaadb.i r1b.4co0m0/ tePsat tient is taken to the operating room for organ retrieval. 1800 All organs have b een retrieved for donation. The ventilator is discontinued. 1810 Cardiac monitor shows fla tline. What is the official time of death recorded in the medical record?
- A. 1300
- B. 1330
- C. 1400
- D. 1800
Correct Answer: E
Rationale: The correct answer is not provided, but based on the events described, the official time of death recorded in the medical record should be 1810 (Choice D). At this time, the cardiac monitor shows flatline, indicating the cessation of cardiac activity, which is the universally accepted point of declaring death.
Choice A (1300) is incorrect because that is when diagnostic tests for brain death were completed, but the patient was not officially declared dead at that time.
Choice B (1330) is incorrect as this is when the primary care provider reviewed the test results and documented brain death in the progress note, but the patient was not officially declared dead at this time either.
Choice C (1400) is incorrect as there is no significant event occurring at this time that signifies the patient's death.
Therefore, the most appropriate and official time of death recorded in the medical record would be 1810 when the cardiac monitor shows flatline.
The charge nurse is supervising the care of four critical ca re patients being monitored using invasive hemodynamic modalities. Which patient should t he charge nurse evaluate first?
- A. A patient in cardiogenic shock with a cardiac output (CabOirb). coofm 2/te.0st L/min
- B. A patient with a pulmonary artery systolic pressure (PA P) of 20 mm Hg
- C. A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg
- D. A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg
Correct Answer: A
Rationale: The correct answer is A because the patient in cardiogenic shock with a cardiac output of 2.0 L/min is experiencing a life-threatening condition that requires immediate evaluation. Cardiogenic shock indicates poor cardiac function, which can lead to multi-organ failure. Monitoring cardiac output is crucial in managing these patients.
Choice B is incorrect because a pulmonary artery systolic pressure of 20 mm Hg is within normal range and does not indicate an immediate life-threatening condition.
Choice C is incorrect because a CVP of 6 mm Hg in a hypovolemic patient may indicate volume depletion, but it is not as urgent as the patient in cardiogenic shock.
Choice D is incorrect because a PAOP of 10 mm Hg is within normal range and does not suggest an immediate critical condition.
The nurse notes premature ventricular contractions (PVCs) while suctioning a patient’s endotracheal tube. Which action by the nurse is a priority?
- A. Decrease the suction pressure to 80 mm Hg.
- B. Document the dysrhythmia in the patient’s chart.
- C. Stop and ventilate the patient with 100% oxygen.
- D. Give antidysrhythmic medications per protocol.
Correct Answer: C
Rationale: The correct answer is C: Stop and ventilate the patient with 100% oxygen. This is the priority action because PVCs can lead to life-threatening arrhythmias and inadequate oxygenation. By stopping suctioning and providing 100% oxygen, the nurse ensures proper oxygenation and ventilation, which takes precedence over addressing the dysrhythmia itself. Decreasing suction pressure (choice A) may not address the underlying issue and could potentially harm the patient. Documenting the dysrhythmia (choice B) is important but not as urgent as ensuring adequate oxygenation. Giving antidysrhythmic medications (choice D) should be done under the direction of a healthcare provider and is not the first-line intervention in this situation.