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A 65-year-old patient admitted to the progressive care unit with a diagnosis of community-acquired pneumonia, has a history of chronic obstructive pulmonary disease and diabetes. A set of arterial blood gases obtained on admissiaobnir bw.coitmh/oteustt supplemental oxygen shows pH 7.35; PaCO 55 mm Hg; bicarbonate 30 mEq/L ; PaO 65 mm Hg. These blood 2 2 gases reflect what condition?
- A. Hypoxemia and compensated metabolic alkalosis.
- B. Hypoxemia and compensated respiratory acidosis.
- C. Normal oxygenation and partly compensated metaboli c alkalosis.
- D. Normal oxygenation and uncompensated respiratory acidosis.
Correct Answer: B
Rationale: The correct answer is B: Hypoxemia and compensated respiratory acidosis. The patient's pH is within normal range (7.35), indicating compensation. The elevated PaCO2 (55 mm Hg) indicates respiratory acidosis due to inadequate ventilation, likely from COPD. The low PaO2 (65 mm Hg) indicates hypoxemia, common in pneumonia. The normal bicarbonate level (30 mEq/L) suggests metabolic compensation for respiratory acidosis. Choice A is incorrect as there is no metabolic alkalosis present. Choice C is incorrect as the patient has hypoxemia. Choice D is incorrect as the patient is showing compensated respiratory acidosis, not uncompensated.
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The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include?
- A. Wear the brace over a T-shirt 23 hours per day.
- B. Dress with the brace over regular clothing.
- C. Shower with the brace directly against the skin.
- D. Remove the brace just before going to bed.
Correct Answer: A
Rationale: The correct answer is A because wearing the Milwaukee brace over a T-shirt ensures proper skin protection and ventilation. This helps prevent skin irritation and allows for comfortable wearing for long periods. Choice B may cause skin issues due to friction. Choice C is incorrect as moisture from showering can lead to skin problems. Choice D is incorrect as consistent wear is crucial for brace effectiveness.
Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?
- A. The patient’s oxygen saturation is 93%.
- B. The patient was last suctioned 6 hours ago.
- C. The patient’s respiratory rate is 32 breaths/minute.
- D. The patient has occasional audible expiratory wheezes.
Correct Answer: C
Rationale: The correct answer is C because a respiratory rate of 32 breaths/minute indicates increased work of breathing, which could be due to secretions that need to be suctioned. High respiratory rate may suggest inadequate oxygenation and ventilation. Oxygen saturation of 93% (choice A) is within an acceptable range and does not necessarily indicate the need for suctioning. Time since last suctioning (choice B) should be considered but is not as immediate an indication as an increased respiratory rate. Occasional audible expiratory wheezes (choice D) may be indicative of other respiratory issues but do not directly indicate the need for suctioning.
The nurse is caring for a mechanically ventilated patient an d is charting outside the patient’s room when the ventilator alarm sounds. What is the priorit y order for the nurse to complete these actions? (Put a comma and space between each answer choice.)
- A. Check quickly for possible causes of the alarm that can be fixed.
- B. After troubleshooting, connect back to mechanical venti lator and reassess patient.
- C. Go to patient’s bedside.
- D. Manually ventilate the patient while getting respiratory therapist.
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Going to the patient’s bedside is the priority as it allows the nurse to assess the patient's condition directly.
2. By being at the bedside, the nurse can quickly evaluate the patient's breathing, vital signs, and other indicators for immediate action.
3. Direct assessment enables timely intervention and avoids delays in addressing potential life-threatening situations.
4. Checking for possible causes of the alarm and reconnection to the ventilator can follow, but assessing the patient's immediate needs takes precedence.
In summary, choice C is correct because direct patient assessment is the fundamental step in responding to a ventilator alarm to ensure patient safety and timely intervention. Choices A, B, and D are incorrect as they focus on troubleshooting and technical aspects before directly assessing the patient's condition.
The nurse is caring for a very seriously ill patient in the CCU. The family visits sporadically, stays for only a short time, and does not ask many questions. How could the nurse best begin to involve the family in the patients care?
- A. Ask one family member to assist with the patients bath.
- B. Encourage family members to stay longer at each visit.
- C. Focus nursing efforts on the patients legal next of kin.
- D. Ask the family to complete the Critical Care Family Needs Inventory.
Correct Answer: D
Rationale: The correct answer is D: Ask the family to complete the Critical Care Family Needs Inventory. This tool helps assess the family's needs and concerns, enabling the nurse to tailor care accordingly. By understanding the family's specific needs, the nurse can provide appropriate support and information, fostering better involvement and understanding.
A: Asking one family member to assist with the patient's bath may not address the overall family's needs or involvement in care.
B: Encouraging family members to stay longer does not necessarily address their specific needs or facilitate effective communication.
C: Focusing solely on the legal next of kin may exclude important family members who also need support and involvement in the patient's care.
The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 12 5 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO ) of 90% on a 50% venturi mask. 2 Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pres sure (PAOP) of 3 mm Hg. The nurse questions which of the following primary health care provider’s order?
- A. Titrate supplemental oxygen to achieve a SpO > 94%a. birb.com/test
- B. Infuse 500 mL 0.9% normal saline over 1 hour.
- C. Obtain arterial blood gas and serum electrolytes.
- D. Administer furosemide 20 mg intravenously.
Correct Answer: D
Rationale: The correct answer is D: Administer furosemide 20 mg intravenously. In this scenario, the patient is hypotensive with a low cardiac output, low CVP, and low PAOP, indicating cardiogenic shock. Administering furosemide, a diuretic, can worsen the patient's condition by further decreasing preload. This can lead to a decrease in cardiac output and exacerbate the shock state. The other options are more appropriate:
A: Titrate supplemental oxygen to achieve a SpO > 94% - Correct, as improving oxygenation is essential in cardiogenic shock.
B: Infuse 500 mL 0.9% normal saline over 1 hour - Correct, as fluid resuscitation may be necessary to improve perfusion.
C: Obtain arterial blood gas and serum electrolytes - Correct, as these tests provide valuable information about the patient's oxygenation and electrolyte balance.