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Which assessment would cue the nurse to the potential of aa bc iru bt .ce o mre /ts ep sti ratory distress syndrome (ARDS) in a patient admitted with respiratory distress?
- A. Increased oxygen saturation via pulse oximetry
- B. Increased peak inspiratory pressure on the ventilator
- C. Normal chest radiograph with enlarged cardiac structures
- D. PaO /FiO ratio > 300 2 2
Correct Answer: B
Rationale: The correct answer is B. Increased peak inspiratory pressure on the ventilator would cue the nurse to the potential of ARDS in a patient with respiratory distress. ARDS is characterized by severe respiratory failure with bilateral pulmonary infiltrates. An increase in peak inspiratory pressure on the ventilator indicates that the lungs are becoming stiffer, which is a common finding in ARDS due to increased inflammation and fluid accumulation in the alveoli. This finding alerts the nurse to the possibility of ARDS and the need for further assessment and intervention.
Summary of other choices:
A: Increased oxygen saturation via pulse oximetry is a nonspecific finding and may not specifically indicate ARDS.
C: Normal chest radiograph with enlarged cardiac structures is more indicative of heart failure rather than ARDS.
D: PaO2/FiO2 ratio > 300 is a criterion used to diagnose ARDS, but a value higher than 300 actually indicates mild ARDS, so it would not necessarily cue the nurse
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The nursing is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention?
- A. Apply a pressure dressing to the insertion site.
- B. Ensure all tubing connections are tightened.
- C. Obtain a portable x-ray to confirm placement.
- D. Restrain the affected extremity for 24 hours.
Correct Answer: C
Rationale: The correct answer is C: Obtain a portable x-ray to confirm placement. This is the priority intervention because it ensures the arterial line is correctly positioned, reducing the risk of complications such as dislodgement or improper placement. Applying a pressure dressing (choice A) may be necessary but is not the priority. Ensuring tubing connections are tightened (choice B) is important for preventing leaks but does not address placement. Restraining the affected extremity (choice D) is unnecessary and can lead to complications. The x-ray confirms correct placement, ensuring accurate monitoring and treatment.
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.
A patient is experiencing severe pain, despite receiving pain medication for the past 24 hours. The patients wife expresses concern about this to the nurse. Which response by the nurse would be most empowering to the patients family?
- A. Explain that the doctor is an expert on pain medication and that the current level ofm edication is the best.
- B. Recommend that the family members take turns massaging the patients feet todistract from the pain.
- C. Encourage the family to request that the physician evaluate the patients pain control.
- D. Ask the family to wait another 24 hours to see whether the patients pain level will go down.
Correct Answer: C
Rationale: The correct answer is C because it empowers the family to take action by requesting a physician evaluation of the patient's pain control. This step is crucial in ensuring that the patient's pain is adequately managed. By involving the physician, the family can advocate for the patient's needs and potentially explore alternative pain management strategies.
Choice A is incorrect because it dismisses the family's concerns and fails to address the need for further evaluation. Choice B may provide temporary relief but does not address the underlying issue of inadequate pain control. Choice D is incorrect as it suggests delaying action, which could lead to prolonged suffering for the patient.
The nurse is caring for 80-year-old patient who has been tr eated for gastrointestinal bleeding. The family has agreed to withhold or withdraw additional treatment. The patient has a written advance directive specifying requests. The directive notes that the patient wants food and fluid to be continued and to be made physically comfortable. Th e nurse anticipates that several orders may be written to comply with this request, including which of the following? (Select all that apply.)
- A. “Do not resuscitate.”
- B. Change antibiotic to a less expensive medication.
- C. Discontinue tube feeding.
- D. Stop any further blood transfusions.
Correct Answer: A
Rationale: The correct answer is A: "Do not resuscitate." In this scenario, the patient's advance directive specifies a desire for comfort measures and continuation of food and fluids. A DNR order aligns with this directive by respecting the patient's wish to avoid aggressive life-saving measures. This choice prioritizes the patient's autonomy and quality of life. Other options (B, C, D) are not aligned with the patient's wishes. Changing antibiotics or stopping blood transfusions may be unrelated to the patient's comfort or food/fluid preferences. Discontinuing tube feeding goes against the directive's request for food and fluid continuation.
The family members are excited about being transferring t heir loved one from the critical care unit to the intermediate care unit. However, they are also fearful of the change in environment and nursing staff. To reduce relocation stress, the nurse ca n implement what intervention? (Select all that apply.)
- A. Arranging for the nurses on the intermediate care unit to give the family a tour of the new unit.
- B. Contacting the primary care provider to see if the patient can stay one additional day in the critical care unit so that the family can adjus t better to the idea of a transfer.
- C. Ensuring that the patient will be located near the nurse ’s station in the new unit.
- D. Inviting the nurse who will be assuming the patient’s care to meet with the patient and family in the critical care unit prior to transfer.
Correct Answer: A
Rationale: The correct answer is A (Arranging for the nurses on the intermediate care unit to give the family a tour of the new unit) because it helps familiarize the family with the new environment, alleviating their fears. The tour allows them to see where their loved one will be cared for, meet the nursing staff, and ask any questions they may have. This intervention promotes a smooth transition, reduces anxiety, and builds trust.
Choice B is incorrect because delaying the transfer doesn't address the fear of change and can prolong stress. Choice C is incorrect as proximity to the nurse's station may not necessarily reduce relocation stress for the family. Choice D is incorrect because meeting the new nurse in the current unit may not provide the same level of comfort and preparation compared to physically visiting the new unit.