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The nurse is caring for a postoperative patient with chroni c obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia?
- A. Bradycardia
- B. Change in sputum characteristics
- C. Hypoventilation and respiratory acidosis
- D. Pursed-lip breathing
Correct Answer: B
Rationale: The correct answer is B: Change in sputum characteristics. This is a cue for postoperative pneumonia in a COPD patient because it can indicate an infection in the lungs. Postoperative pneumonia is a common complication in patients with COPD due to impaired lung function and weakened immune system. Other choices are incorrect: A) Bradycardia is not a specific indicator of postoperative pneumonia. C) Hypoventilation and respiratory acidosis can be seen in patients with COPD but are not specific to postoperative pneumonia. D) Pursed-lip breathing is a coping mechanism for patients with COPD and is not directly related to postoperative pneumonia.
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A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of:
- A. Peritoneal lavage.
- B. Abdominal ultrasonography.
- C. Nasogastric (NG) tube placement.
- D. Magnetic resonance imaging (MRI).
Correct Answer: B
Rationale: The correct answer is B: Abdominal ultrasonography. This is because ultrasonography is a non-invasive imaging technique that can quickly evaluate for internal injuries such as organ damage or bleeding in patients with blunt abdominal trauma. It is a rapid and effective diagnostic tool to assess the extent of injury and guide further management.
Peritoneal lavage (A) is an invasive procedure used in trauma settings to detect intra-abdominal bleeding but is not typically used for teaching purposes. Nasogastric tube placement (C) is used for decompression and drainage in certain conditions but is not relevant for assessing abdominal trauma. Magnetic resonance imaging (MRI) (D) is not typically used as the initial imaging modality for acute trauma due to time constraints and its limited availability in emergency settings.
Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of acute respiratory distress syndrom e (ARDS)? (Select all that apply.)
- A. Increase functional residual capacity
- B. Prevent collapse of unstable alveoli
- C. Improve arterial oxygenation
- D. Open collapsed alveoli
Correct Answer: A
Rationale: The correct answer is A: Increase functional residual capacity. Positive end-expiratory pressure (PEEP) helps increase the functional residual capacity by keeping the alveoli open at the end of expiration. This prevents alveolar collapse, improves ventilation-perfusion matching, and enhances oxygenation.
B: Prevent collapse of unstable alveoli - This is incorrect because PEEP actually helps prevent the collapse of all alveoli, not just unstable ones.
C: Improve arterial oxygenation - This is partially correct, but the primary mechanism through which PEEP improves oxygenation is by increasing functional residual capacity.
D: Open collapsed alveoli - This is incorrect because PEEP helps prevent alveolar collapse rather than actively opening already collapsed alveoli.
A new nurse has recently joined the ICU from a different hospital, which had a much stricter policy regarding visiting hours. She expresses concern about the impact of open visiting hours on patient well-being. Which of the following would be the best explanation for the purpose of open visiting hours? Select all that apply.
- A. To better provide rest and quiet
- B. To strengthen the relationship between the family and health care provider
- C. To control the number of visitors for a patient
- D. To provide an undisturbed environment
Correct Answer: B
Rationale: The correct answer is B: To strengthen the relationship between the family and health care provider.
Rationale:
1. Open visiting hours encourage family involvement in care, fostering a partnership between healthcare providers and families.
2. Family support can positively impact patient outcomes and satisfaction.
3. It allows families to be updated on the patient's condition and involved in decision-making.
4. Strengthening the relationship can lead to better communication and trust between all parties.
Summary of Incorrect Choices:
A: Open visiting hours may disrupt rest and quiet, but the primary purpose is not to provide rest.
C: Open visiting hours do not aim to control the number of visitors but rather encourage family involvement.
D: While open visiting hours may not provide an entirely undisturbed environment, the focus is on improving family-provider relationships.
A patient with terminal cancer reports a sudden onset of severe pain. Which intervention should the nurse implement first?
- A. Assess the patient’s pain using a standardized pain scale.
- B. Administer a PRN dose of prescribed analgesic.
- C. Notify the healthcare provider about the patient’s pain.
- D. Reposition the patient to enhance comfort.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient’s pain using a standardized pain scale. The first step is to assess the severity and nature of the pain to determine the appropriate intervention. This allows the nurse to understand the pain intensity and characteristics, which guides the choice of analgesic and dosing. Administering analgesics (B) without proper assessment can lead to inappropriate treatment. Notifying the healthcare provider (C) is important but assessing the pain should come first. Repositioning the patient (D) may provide comfort but addressing the pain directly is the priority.
In the critically ill patient, an incomplete assessment and/or management of pain or anxiety may be hampered by which of the following? (Select all that apply.)
- A. Administration of neuromuscular blocking agents
- B. Delirium
- C. Effective nurse communication and assessment skills
- D. Nonverbal patients
Correct Answer: A
Rationale: Step-by-step rationale:
1. Administration of neuromuscular blocking agents can hinder pain or anxiety assessment as it paralyzes the patient, preventing them from communicating discomfort.
2. Delirium may affect the patient's ability to express pain or anxiety, but it does not directly impede assessment and management.
3. Effective nurse communication and assessment skills facilitate, rather than hamper, pain or anxiety assessment.
4. Nonverbal patients can still communicate pain or anxiety through nonverbal cues, so they do not necessarily hinder assessment.