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When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87°F (30.6°C), which assessment indicates that the nurse should discontinue active rewarming?
- A. The patient begins to shiver.
- B. The BP decreases to 86/42 mm Hg.
- C. The patient develops atrial fibrillation.
- D. The core temperature is 94°F (34.4°C).
Correct Answer: D
Rationale: The correct answer is D. When rewarming a hypothermic patient, the goal is to gradually increase their core temperature. A core temperature of 94°F (34.4°C) is still below the normal range, but it indicates that the rewarming process is working. Shivering (A) is a normal response to rewarming. A decrease in blood pressure (B) may be expected due to peripheral vasodilation during rewarming. Developing atrial fibrillation (C) may be a concern but does not necessarily indicate that rewarming should be discontinued. Therefore, choice D is correct as it signifies progress in the rewarming process.
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Ideally, by whom and when should an advance directive be developed?
- A. Family, if the patient is in critical condition.
- B. Patient as part of the hospital admission process.
- C. Patient before illness or impairment occurs.
- D. Patient’s healthcare surrogate.
Correct Answer: C
Rationale: Step-by-step rationale for choice C:
1. Advance directives should be made by the patient to reflect their wishes.
2. Developing it before illness ensures clarity and avoids confusion.
3. Patients may not be able to make informed decisions in critical conditions.
4. Family or surrogates may not accurately represent the patient's wishes.
Summary:
A - Family in critical condition may not know the patient's wishes.
B - Hospital admission process may be too late for clear decision-making.
D - Healthcare surrogate may not fully understand the patient's preferences.
A normal glomerular filtration rate is
- A. less than 80 mL/min.
- B. 80 to 125 mL/min.
- C. 125 to 180 mL/min.
- D. more than 189 mL/min.
Correct Answer: B
Rationale: The correct answer is B (80 to 125 mL/min) because this range reflects the normal glomerular filtration rate (GFR) in adults. GFR measures the rate at which blood is filtered by the kidneys, typically around 125 mL/min. A GFR below 60 mL/min indicates kidney dysfunction, making option A incorrect. Option C (125 to 180 mL/min) is above the normal range. Option D (more than 189 mL/min) is too high and could indicate hyperfiltration, common in conditions like diabetes. Therefore, choice B is the most appropriate within the normal GFR range.
In assessing a patient, the nurse understands that what sym ptomology is an early sign of hypoxemia?
- A. Clubbing of nail beds
- B. Cyanosis
- C. Hypotension
- D. Restlessness
Correct Answer: D
Rationale: Step 1: Restlessness is an early sign of hypoxemia due to the body's response to low oxygen levels.
Step 2: Restlessness occurs as the body tries to increase oxygen intake.
Step 3: Other choices are incorrect because clubbing and cyanosis are late signs, while hypotension is not a specific early sign of hypoxemia.
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should:
- A. Obtain a complete set of vital signs.
- B. Obtain a Glasgow Coma Scale score.
- C. Ask about chronic medical conditions.
- D. Attach a cardiac electrocardiogram monitor.
Correct Answer: B
Rationale: The correct answer is B: Obtain a Glasgow Coma Scale score. During the primary survey, assessing the patient's level of consciousness is crucial as it helps determine the severity of the injury and guides further management. The Glasgow Coma Scale is a standardized tool used to assess the level of consciousness based on eye opening, verbal response, and motor response. It provides valuable information about the patient's neurological status.
A: Obtaining a complete set of vital signs is important but assessing the level of consciousness takes priority in this scenario.
C: Asking about chronic medical conditions is important but not as critical as assessing the patient's level of consciousness during the primary survey.
D: Attaching a cardiac electrocardiogram monitor is not necessary during the primary survey unless there are specific indications of cardiac issues, which are not evident in this case.
In summary, obtaining a Glasgow Coma Scale score is essential for assessing the patient's level of consciousness and determining the severity of the injury during the primary survey.
The nurse is caring for a critically ill patient who can speak. The nurse notices that the patient is demonstrating behaviors indicative of anxiety but is silent. What nursing strategy would give the nurse the most information about the patients feelings?
- A. Explain procedures to the patient and family.
- B. Ask the patient to share his or her internal dialogue.
- C. Encourage the patient to nap before visiting hours.
- D. Ensure that the patient has adequate pain control.
Correct Answer: B
Rationale: The correct answer is B because asking the patient to share his or her internal dialogue can provide direct insight into the patient's thoughts and feelings, allowing the nurse to address specific anxieties. This approach promotes open communication and understanding. Choice A focuses on providing information but may not directly address the patient's feelings. Choice C is unrelated to addressing the patient's anxiety. Choice D addresses pain control, which is important but not directly related to exploring the patient's emotions. Therefore, option B is the most effective strategy for gaining insight into the patient's feelings in this scenario.