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Which is likely the most common recollection from a patie nt who required endotracheal intubation and mechanical ventilation?
- A. Difficulty communicating
- B. Inability to get comfortable
- C. Pain
- D. Sleep disruption
Correct Answer: A
Rationale: The correct answer is A: Difficulty communicating. When a patient undergoes endotracheal intubation and mechanical ventilation, they are unable to speak normally. This leads to frustration and anxiety due to the inability to communicate effectively with healthcare providers and loved ones. The lack of communication can also impact their emotional well-being. Choices B, C, and D are less likely as the most common recollection because patients might not remember feeling uncomfortable, experiencing pain, or having sleep disruption during sedation and ventilation. Additionally, the inability to communicate is a primary concern for patients in this situation.
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The nurse is caring for a patient who has an intra-aortic balloon pump (IABP) following a massive heart attack. When assessing the patient, the nurse notices blood backing up into the IABP catheter. In which order should the nurse take the following actions?
- A. Ensure that the IABP console has been turned off.
- B. Assess the patient's vital signs and orientation.
- C. Notify the healthcare provider of the IABP malfunction.
- D. Obtain supplies for insertion of a new IABP catheter.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Ensuring the IABP console is turned off is crucial to prevent further complications and stop potential harm to the patient.
2. By turning off the IABP console, the nurse can halt the pumping action, allowing assessment of the situation without interference.
3. This action takes priority over other steps as it addresses the immediate issue of blood backing up into the IABP catheter.
4. Once the console is turned off, the nurse can proceed with assessing the patient's vital signs, notifying the healthcare provider, and obtaining supplies if needed.
Summary of Incorrect Choices:
- Option B: Assessing vital signs and orientation is important, but addressing the malfunction of the IABP takes precedence to prevent harm.
- Option C: Notifying the healthcare provider is necessary, but first, the immediate issue of blood backing up into the catheter must be addressed.
- Option D: Obtaining supplies for a new catheter is premature without first addressing
The nurse is caring for a patient who requires administration of a neuromuscular blocking (NMB) agent to facilitate ventilation with non-traditional m odes. The nurse understands that neuromuscular blocking agents provide what outcome?
- A. Lessened antianxiety
- B. Complete analgesia.
- C. High levels of sedation.
- D. No sedation or analgesia.
Correct Answer: D
Rationale: The correct answer is D: No sedation or analgesia. Neuromuscular blocking agents do not provide sedation or pain relief; they solely act on skeletal muscles to induce paralysis for procedures like intubation. Choice A is incorrect because NMB agents do not affect anxiety levels. Choice B is incorrect because NMB agents do not provide analgesia. Choice C is incorrect because NMB agents do not induce sedation. The primary purpose of NMB agents is to induce muscle paralysis without affecting consciousness or pain perception.
The nurse cites evidence-based practice as a rationale for a patient care decision. What isthe best description of evidence-based practice?
- A. Decisions based on expert legal testimony
- B. Use of best available research data
- C. Evolution of nursing practice over time
- D. Individual optimization of patient outcomes
Correct Answer: B
Rationale: The correct answer is B: Use of best available research data. Evidence-based practice involves integrating the best available research evidence with clinical expertise and patient values to make informed decisions about patient care. It emphasizes using scientifically proven data to guide practice and improve patient outcomes. Expert legal testimony (A) is not necessarily evidence-based. Evolution of nursing practice over time (C) does not specifically focus on research data. Individual optimization of patient outcomes (D) is a goal of evidence-based practice, but it does not fully encompass the concept.
The patient’s significant other is terrified by the prospect o f removing life-sustaining treatments from the patient and asks why anyone would do that. What explanation should the nurse provide?
- A. “It is to save you money so you won’t have such a large financial burden.”
- B. “It will preserve limited resources for the hospital so oatbhirebr.c pomat/tieesnt ts may benefit from them.”
- C. “It is to discontinue treatments that are not helping and may be very uncomfortable.”
- D. “We have done all we can for your wife and any more treatment would be futile.”
Correct Answer: C
Rationale: The correct answer is C because it explains that the decision to remove life-sustaining treatments is based on the fact that these treatments are not helping the patient and may actually be causing discomfort. This rationale aligns with the principle of beneficence, which emphasizes doing good and avoiding harm to the patient. It also respects the patient's autonomy by prioritizing their well-being and quality of life.
Choice A is incorrect as it focuses on financial reasons rather than the patient's best interest. Choice B is incorrect because it prioritizes hospital resources over individual patient care. Choice D is incorrect as it lacks clarity and may come across as insensitive to the significant other's concerns.
Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: “The tip of the catheter is located in the superior vena cava.” What is the best inter pretation of these results by the nurse?
- A. The catheter is not positioned correctly and should be removed.
- B. The catheter position increases the risk of ventricular daybisrbr.hcoymth/tmesti as.
- C. The distal tip of the catheter is in the appropriate position.
- D. The physician should be called to advance the catheter into the pulmonary artery.
Correct Answer: C
Rationale: The correct answer is C: The distal tip of the catheter is in the appropriate position.
Rationale:
1. The superior vena cava is a desirable location for a central venous catheter tip placement as it is close to the heart for rapid medication delivery.
2. Catheter tip in the superior vena cava allows for proper venous return and minimizes the risk of complications.
3. The nurse does not need to remove or adjust the catheter if the tip is in the superior vena cava.
4. Advancing the catheter into the pulmonary artery (option D) would be incorrect as it can lead to serious complications.
Incorrect choices:
A: Incorrect because placement in the superior vena cava is acceptable.
B: Incorrect as placement in the superior vena cava does not increase the risk of ventricular dysrhythmias.
D: Incorrect as advancing the catheter into the pulmonary artery is unnecessary and risky.