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Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action?
- A. The right hand is cooler than the left.
- B. The mean arterial pressure (MAP) is 77 mm Hg.
- C. The system is delivering 3 mL of flush solution per hour.
- D. The flush bag and tubing were last changed 3 days previously.
Correct Answer: A
Rationale: The correct answer is A because a cooler right hand may indicate compromised circulation, potentially due to arterial occlusion or clot formation. This could lead to inadequate perfusion and tissue damage. Immediate action is needed to assess and address the cause.
Choice B is incorrect because a MAP of 77 mm Hg is within the normal range for most patients and does not require immediate action.
Choice C is incorrect as delivering 3 mL of flush solution per hour is an appropriate rate and does not indicate a need for immediate action.
Choice D is incorrect as the flush bag and tubing being changed 3 days ago does not necessarily indicate an immediate issue with the arterial line function.
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The nurse recognizes that which patient is likely to benefit most from patient-controlled analgesia?
- A. 21-year-old with a C4 fracture and quadriplegia
- B. 45-year-old with femur fracture and closed head injury
- C. 59-year-old postoperative elective bariatric surgery
- D. 70-year-old postoperative cardiac surgery; mild demen tia
Correct Answer: A
Rationale: The correct answer is A, the 21-year-old with a C4 fracture and quadriplegia. This patient is likely to benefit most from patient-controlled analgesia (PCA) due to the inability to self-administer traditional pain medications. With quadriplegia, the patient may have limited mobility and sensation, making it challenging to communicate pain levels effectively. PCA allows the patient to control their pain relief within preset limits, enhancing autonomy and optimizing pain management.
Summary:
- Choice B: The 45-year-old with femur fracture and closed head injury may benefit from PCA, but the severity of the head injury could affect their ability to use the device effectively.
- Choice C: The 59-year-old postoperative elective bariatric surgery patient can typically manage pain with traditional methods postoperatively.
- Choice D: The 70-year-old postoperative cardiac surgery patient with mild dementia may have the cognitive ability to use PCA but could potentially benefit more from other pain management strategies due
The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring th e patient from the stretcher to the bed. Prior to obtaining a cardiac output, which action is m ost important for the nurse to complete?
- A. Document a pulmonary artery catheter occlusion press ure.
- B. Zero reference the transducer system at the phlebostatic axis.
- C. Inflate the pulmonary artery catheter balloon with 1 m L air.
- D. Inject 10 mL of 0.9% normal saline into the proximal port.
Correct Answer: B
Rationale: The correct answer is B: Zero reference the transducer system at the phlebostatic axis. This is the most important action before obtaining a cardiac output because zero referencing ensures accurate pressure readings. The phlebostatic axis is the level of the atria when the patient is supine, and zeroing at this point minimizes errors in pressure measurements.
Choice A is incorrect because documenting a pulmonary artery catheter occlusion pressure is not the priority at this stage. Choice C is incorrect as inflating the balloon with air should be done after zero referencing. Choice D is incorrect as injecting normal saline into the port is not necessary before zero referencing.
Which of the following are components of the Institute for Healthcare Improvement’s (IHI’s) ventilator bundle? (Select all that apply.)
- A. Interrupt sedation each day to assess readiness to extub aa bit re b.. c om/test
- B. Maintain head of bed at least 30 degrees elevation.
- C. Provide deep vein thrombosis prophylaxis.
- D. Provide prophylaxis for peptic ulcer disease.
Correct Answer: A
Rationale: The correct answer is A because interrupting sedation daily to assess readiness to extubate is a key component of IHI's ventilator bundle to prevent ventilator-associated pneumonia. This practice helps prevent over-sedation, reduce the duration of mechanical ventilation, and decrease the risk of complications. The other choices, B, C, and D, are incorrect as they are not specific components of the IHI's ventilator bundle. Maintaining head of bed elevation, providing deep vein thrombosis prophylaxis, and prophylaxis for peptic ulcer disease are important aspects of critical care but are not directly related to the ventilator bundle protocol outlined by IHI.
All of the patient’s children are distressed by the possibility of removing life-support treatments. The child who is most upset tells the nurse, “T his is the same as killing! I thought you were supposed to help!” What response would the nur se provide to the family?
- A. “This is a process of allowing death to occur naturally after the injuries that were sustained in a serious accident.”
- B. “The hospital would never allow us to do that kind of thing.”
- C. “Let’s talk about this calmly, and I will explain why asasbiirsbt.ecodm s/tuesict ide is appropriate in this case.”
- D. “Your parent lived a long and productive life.”
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Acknowledges the child's distress and concerns.
2. Explains the concept of allowing natural death after serious injuries.
3. Helps the family understand the ethical and medical reasoning behind removing life support.
4. Shows empathy and provides education to address misconceptions.
Summary of other choices:
B: Incorrect - Avoids addressing the family's concerns and provides a vague response.
C: Incorrect - Contains a typo and does not directly address the child's distress or misunderstanding.
D: Incorrect - Irrelevant response that does not address the ethical dilemma at hand.
A patient presents to the emergency department in acute re spiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation?
- A. Emergency tracheostomy and mechanical ventilation
- B. Mechanical ventilation via an endotracheal tube
- C. Noninvasive positive-pressure ventilation (NPPV)
- D. Oxygen at 100% via bag-valve-mask device
Correct Answer: B
Rationale: The correct answer is B: Mechanical ventilation via an endotracheal tube. In acute respiratory failure, especially in the setting of pneumonia and COPD, mechanical ventilation is often necessary to support breathing. Endotracheal intubation allows for precise control of airway patency, oxygenation, and ventilation. Emergency tracheostomy (choice A) is typically reserved for long-term ventilatory support. Noninvasive positive-pressure ventilation (choice C) may not provide sufficient support in severe cases. Oxygen via bag-valve-mask (choice D) may not be adequate for ventilatory support in acute respiratory failure.