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The nurse is managing a donor patient six hours prior to th e scheduled harvesting of the patient’s organs. Which assessment finding requires imme diate action by the nurse?
- A. Morning serum blood glucose of 128 mg/dL
- B. pH 7.30; PaCO 38 mm Hg; HCO 16 mEq/L 2 3
- C. Pulmonary artery temperature of 97.8° F
- D. Central venous pressure of 8 mm Hg
Correct Answer: B
Rationale: The correct answer is B. The patient's pH of 7.30 indicates acidosis, PaCO2 of 38 mm Hg is low, and HCO3 of 16 mEq/L is also low, suggesting metabolic acidosis. This finding requires immediate action as untreated acidosis can lead to serious complications.
Choice A (morning serum blood glucose of 128 mg/dL) is within normal range and does not require immediate action.
Choice C (pulmonary artery temperature of 97.8°F) is a normal temperature and does not require immediate action.
Choice D (central venous pressure of 8 mm Hg) is within normal range and does not require immediate action.
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The primary care provider orders the following mechanica l ventilation settings for a patient who weighs 75 kg and whose spontaneous respiratory rate is 22 breaths/min. What arterial blood gas abnormality may occur if the patient continues taob ibrbe.c otamc/thesyt pneic at these ventilator settings? Settings: Tidal volume: 600 mL (8 mL per kg) FiO 2: 0.5 Respiratory rate: 14 breaths/min Mode assist/control Positive end-expiratory pressure: 10 cm H O
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: C
Rationale: The correct answer is C: Respiratory acidosis may occur if the patient continues at these ventilator settings. Respiratory acidosis happens when the lungs cannot remove enough of the carbon dioxide (CO2) produced by the body. In this case, the low respiratory rate of 14 breaths/min may not be sufficient to adequately remove CO2, leading to its accumulation in the blood. This results in a decrease in blood pH, causing respiratory acidosis.
Summary of other choices:
A: Metabolic acidosis - Not the correct answer as the ventilator settings are more likely to affect the respiratory system rather than the metabolic system.
B: Metabolic alkalosis - Not the correct answer as the ventilator settings are not related to causing an increase in blood pH, which is characteristic of metabolic alkalosis.
D: Respiratory alkalosis - Not the correct answer as the low respiratory rate would not lead to excessive elimination of CO2, causing alkalosis.
The nurse cares for a terminally ill patient who is experiencing pain that is continuous and severe. How should the nurse schedule the administration of opioid pain medications?
- A. Give around-the-clock routine administration of analgesics.
- B. Provide PRN doses of medication whenever the patient requests.
- C. Offer enough pain medication to keep the patient sedated.
- D. Suggest analgesic doses that provide pain control without decreasing respiratory rate.
Correct Answer: A
Rationale: The correct answer is A: Give around-the-clock routine administration of analgesics. This is the best approach for managing continuous and severe pain in a terminally ill patient. By providing scheduled doses of opioid pain medications, the nurse ensures a consistent level of pain relief, preventing peaks and troughs in pain control. This approach also helps in preventing the patient from experiencing unnecessary suffering.
Choice B (PRN doses) may lead to inadequate pain control as the patient may wait too long before requesting medication. Choice C (keeping the patient sedated) is not appropriate as the goal is pain management, not sedation. Choice D (balancing pain control and respiratory rate) is important, but the priority should be on effectively managing the pain first.
A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?
- A. Has the client experienced constipation recently?
- B. Did the client miss any doses of the medication?
- C. How long has the client been taking the medication?
- D. Does the client use any tobacco products?
Correct Answer: C
Rationale: The correct answer is C. Assessing how long the client has been taking clonidine is crucial as drowsiness is a common side effect that typically improves over time as the body adjusts to the medication. This information helps determine if the drowsiness is a temporary side effect or a more concerning issue.
Choice A (constipation) is not directly related to drowsiness as a side effect of clonidine. Choice B (missed doses) may contribute to drowsiness but is not the primary assessment priority. Choice D (tobacco use) is not directly related to clonidine-induced drowsiness.
The nurse is caring for a patient with acute respiratory dist ress syndrome who is hypoxemic despite mechanical ventilation. The primary care provider (PCP) orders a nontraditional ventilator mode as part of treatment. Despite sedation and aabnirba.lcgoems/tieas,t the patient remains restless and appears to be in discomfort. The nurse informs the PCP of this assessment and anticipates what order?
- A. Continuous lateral rotation therapy
- B. Guided imagery
- C. Neuromuscular blockade
- D. Prone positioning
Correct Answer: C
Rationale: The correct answer is C: Neuromuscular blockade.
1. Neuromuscular blockade helps to achieve optimal ventilator synchrony by reducing patient-ventilator asynchrony and improving oxygenation in patients with acute respiratory distress syndrome (ARDS).
2. Despite sedation, the patient's restlessness and discomfort suggest inadequate ventilator synchrony, which can be addressed by neuromuscular blockade.
3. Continuous lateral rotation therapy (A) and prone positioning (D) are interventions for improving ventilation and oxygenation in ARDS but do not directly address patient-ventilator synchrony.
4. Guided imagery (B) is a non-pharmacological technique for relaxation and pain management, which may not address the underlying issue of ventilator synchrony in this case.
The charge nurse is responsible for making the patient ass ignments on the critical care unit. She assigns the experienced, certified nurse to care for thea abicrbu.cteomly/t eisltl patient diagnosed with sepsis who also requires continuous renal replacement therapy and mechanical ventilation. She assigns the nurse with less than 1 year of experience to two patients who are more stable. This assignment reflects implementation of what guiding framework?
- A. Crew resource management model
- B. National Patient Safety Goals
- C. Quality and Safety Education for Nurses (QSEN) mod el
- D. Synergy model of practice
Correct Answer: D
Rationale: The correct answer is D: Synergy model of practice. The Synergy model emphasizes matching nurse competencies with patient needs for optimal outcomes. In this scenario, the charge nurse assigned the experienced, certified nurse to a complex patient requiring specialized care (sepsis, renal replacement therapy, ventilation), aligning with the model's principle of matching nurse expertise to patient acuity. Assigning the less experienced nurse to stable patients aligns with the model's focus on optimizing patient outcomes by matching nurse competencies appropriately.
A: Crew resource management model focuses on teamwork and communication to enhance safety, not specifically on nurse-patient assignments.
B: National Patient Safety Goals are broad guidelines for improving patient safety, not specific to nurse-patient assignments.
C: Quality and Safety Education for Nurses (QSEN) model focuses on integrating quality and safety competencies into nursing education, not specifically on nurse-patient assignments.