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Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?
- A. The patient’s oxygen saturation is 93%.
- B. The patient was last suctioned 6 hours ago.
- C. The patient’s respiratory rate is 32 breaths/minute.
- D. The patient has occasional audible expiratory wheezes.
Correct Answer: C
Rationale: The correct answer is C because a respiratory rate of 32 breaths/minute indicates increased work of breathing, which could be due to secretions that need to be suctioned. High respiratory rate may suggest inadequate oxygenation and ventilation. Oxygen saturation of 93% (choice A) is within an acceptable range and does not necessarily indicate the need for suctioning. Time since last suctioning (choice B) should be considered but is not as immediate an indication as an increased respiratory rate. Occasional audible expiratory wheezes (choice D) may be indicative of other respiratory issues but do not directly indicate the need for suctioning.
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After a change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first?
- A. Patient who failed a spontaneous breathing trial and has been placed in rest mode on the ventilator.
- B. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring.
- C. Patient with central venous oxygen saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP).
- D. Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours.
Correct Answer: D
Rationale: The correct answer is D - Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours. This patient should be assessed first because the absence of urine output for 6 hours after being extubated could indicate acute kidney injury or other serious complications that need immediate attention. Urine output is a crucial indicator of renal function and can reflect the patient's overall hemodynamic status. In contrast, the other choices do not present immediate life-threatening conditions. Choice A involves a patient in rest mode post-failed breathing trial, which does not require immediate assessment. Choice B mentions continuous PETCO2 monitoring, which is important but not as urgent as assessing a patient with no urine output. Choice C describes a patient with a ScvO2 of 69%, which may need monitoring but does not indicate an urgent priority compared to assessing a patient with no urine output after recent extubation.
A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam 1 to 2 mg IV as needed (prn). The patient has received no lorazepam during this course of illness. What is the most appropriate nursing intearbvirbe.ncotmio/tnes tt o control agitation?
- A. Administer fentanyl (Duragesic) 25 mg IV bolus.
- B. Administer midazolam 2 mg IV now.
- C. Increase the rate of the morphine infusion by 50%.
- D. Request an order for a paralytic agent.
Correct Answer: B
Rationale: Step-by-step rationale for why choice B is correct:
1. Midazolam is a benzodiazepine used for sedation and anxiolysis.
2. It acts quickly and has a short duration of action, suitable for acute agitation.
3. Lorazepam (also a benzodiazepine) is in the same drug class, ensuring compatibility.
4. Lorazepam is specifically ordered for this patient, indicating its appropriateness.
5. Administering midazolam addresses the patient's agitation efficiently and safely.
Summary of why other choices are incorrect:
A: Fentanyl is an opioid analgesic, not ideal for managing agitation.
C: Increasing morphine infusion can exacerbate sedation or respiratory depression.
D: Paralytic agents are used for neuromuscular blockade, not agitation control.
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 patient requires neuromuscular blockade (NMB) as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes which interventions? (Select all that apply.)
- A. Administration of sedatives concurrently with neuromuscular blockade.
- B. Dangling the patient’s feet over the edge of the bed an d assisting the patient to sit up in a chair at least twice each day.
- C. Ensuring that deep vein thrombosis prophylaxis is initi ated.
- D. providing interventions for eye care, oral care, and skin care.
Correct Answer: C
Rationale: The correct answer is C: Ensuring that deep vein thrombosis prophylaxis is initiated. When a patient requires neuromuscular blockade for increased intracranial pressure, they are likely immobile, which increases the risk of deep vein thrombosis (DVT). Initiating DVT prophylaxis, such as compression stockings or anticoagulant therapy, helps prevent blood clot formation.
Choice A is incorrect because sedatives can mask signs of neurologic deterioration in this patient population. Choice B is incorrect as it promotes activities that may increase intracranial pressure and could be harmful. Choice D, while important for overall patient care, is not directly related to the specific nursing interventions required for a patient receiving neuromuscular blockade for increased intracranial pressure.
A nurse decides to seek certification in critical care nursing. What is the most important benefit for the individual nurse in becoming certified in a specialty?
- A. It will result in a salary increase.
- B. It is required to work in critical care.
- C. It demonstrates the nurses personal expertise.
- D. It is mandated by employers.
Correct Answer: C
Rationale: The correct answer is C because obtaining certification in critical care nursing demonstrates the nurse's personal expertise in the specialty. Certification confirms the nurse's advanced knowledge and skills, enhancing professional credibility and potential for career advancement. This choice focuses on the individual nurse's competency and dedication to the specialty.
Incorrect choices:
A: Salary increase is not the primary benefit of certification, although it may be a potential outcome.
B: Certification is often preferred but not always required to work in critical care.
D: Employers may encourage certification, but it is not always mandated.