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An intra-aortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met?
- A. Urine output of 25 mL/hr.
- B. Heart rate of 110 beats/minute.
- C. Cardiac output (CO) of 5 L/min.
- D. Stroke volume (SV) of 40 mL/beat.
Correct Answer: C
Rationale: The correct answer is C: Cardiac output (CO) of 5 L/min. In cardiogenic shock, the primary goal of using an IABP is to improve cardiac output to ensure adequate perfusion to vital organs. A cardiac output of 5 L/min indicates adequate blood flow and perfusion.
Choice A is incorrect as urine output is not a direct indicator of cardiac function. Choice B is incorrect as a heart rate of 110 beats/minute alone does not provide information on the effectiveness of the IABP in improving cardiac output. Choice D is incorrect as stroke volume alone does not provide a comprehensive assessment of overall cardiac function.
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Continuous venovenous hemodialysis is used to
- A. remove fluids and solutes through the process of convection.
- B. remove plasma water in cases of volume overload.
- C. remove plasma water and solutes by adding dialysate.
- D. combine ultrafiltration, convection and dialysis
Correct Answer: D
Rationale: The correct answer is D because continuous venovenous hemodialysis combines ultrafiltration, convection, and dialysis techniques. Ultrafiltration removes excess fluid, convection helps in removing solutes, and dialysis involves the diffusion of solutes across a semipermeable membrane. This comprehensive approach ensures effective removal of both fluid and solutes in critically ill patients.
Incorrect Answer Analysis:
A: Removing fluids and solutes through convection alone is not the complete process in continuous venovenous hemodialysis.
B: While volume overload is addressed, continuous venovenous hemodialysis involves more than just removing plasma water.
C: Adding dialysate is not the primary method in continuous venovenous hemodialysis; it involves ultrafiltration, convection, and dialysis techniques.
While caring for a patient with a pulmonary artery cathete r, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breat hs/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action?
- A. Increase supplemental oxygen and notify respiratory therapy.
- B. Notify the physician immediately of the assessment fin dings.
- C. Obtain a stat chest x-ray film to verify proper catheter placement.
- D. Zero reference and level the catheter at the phlebostati
Correct Answer: B
Rationale: The correct answer is B: Notify the physician immediately of the assessment findings. The significantly higher PAOP could indicate a potential complication or a change in the patient's condition that needs immediate medical attention. By notifying the physician, further assessment and interventions can be initiated promptly to address the underlying cause. Increasing supplemental oxygen (choice A) may not directly address the elevated PAOP, obtaining a chest x-ray (choice C) may delay urgent intervention, and zero referencing the catheter (choice D) is not a priority in this situation. Notifying the physician ensures timely and appropriate management of the patient's condition.
The patient has been admitted to the hospital with nausea and vomiting that started 5 days earlier. Blood pressure is 80/44 mm Hg and heart rate is 122 beats/min; the patient has not voided in 8 hours, and the bladder is not distended. The nurse anticipates a prescription for “stat” administration of
- A. a blood transfusion.
- B. fluid replacement with 0.45% saline.
- C. infusion of an inotropic agent.
- D. an antiemetic.
Correct Answer: B
Rationale: The correct answer is B: fluid replacement with 0.45% saline. The patient's low blood pressure, tachycardia, and lack of urine output indicate hypovolemia. Fluid replacement with saline will help restore circulating volume, improve blood pressure, and support renal perfusion. A: Blood transfusion is not indicated as the primary issue is hypovolemia, not anemia. C: Inotropic agents are used to increase cardiac contractility but are not the initial treatment for hypovolemia. D: Antiemetics may help with symptoms but do not address the underlying issue of fluid loss and hypovolemia.
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.
The nurse is educating a patient’s family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates undaebrisrbt.acnomd/itnesgt of the purpose of the PAC?
- A. “The catheter will provide multiple sites to give intravenous fluid.”
- B. “The catheter will allow the primary health care provid er to better manage fluid therapy.”
- C. “The catheter tip comes to rest inside my brother’s pul monary artery.”
- D. “The catheter will be in position until the heart has a chance to heal.”
Correct Answer: B
Rationale: The correct answer is B because it shows understanding that the PAC helps in managing fluid therapy effectively. The PAC measures pressures in the heart and lungs, guiding fluid management. Choice A is incorrect as the PAC is not primarily for IV fluid administration. Choice C shows understanding of the catheter placement but not its purpose. Choice D is incorrect as the PAC is not for the heart to heal but to monitor cardiac status.