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A hospice patient is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. Which statement, if made by the nurse to the patient’s family member, is most appropriate?
- A. These symptoms will continue to increase until death finally occurs.
- B. These symptoms are a normal response before these functions decrease.
- C. These symptoms indicate a reflex response to the slowing of other body systems.
- D. These symptoms may be associated with an improvement in the patient’s condition.
Correct Answer: B
Rationale: The correct answer is B because an increase in heart rate and respiratory rate can be a normal response before body system functions decrease in a hospice patient. This is known as a compensatory mechanism as the body tries to maintain oxygenation. Choice A is incorrect because symptoms may not always continue to increase until death. Choice C is incorrect as it implies a reflex response, which may not be the case. Choice D is incorrect as an improvement in the patient's condition is unlikely in a hospice setting.
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The family of a critically ill patient has asked to discuss organ donation with the patient’s nurse. When preparing to answer the family’s questions, th e nurse understands which concern(s) most often influence a family’s decision to donate? (Select all that apply.)
- A. Donor disfigurement influences on funeral care
- B. Fear of inferior medical care provided to donor
- C. Age and location of all possible organ recipients
- D. Concern that donated organs will not be used
Correct Answer: A
Rationale: Rationale for Correct Answer A: Donor disfigurement influences on funeral care. Families often consider the impact of organ donation on the appearance of their loved one during funeral arrangements. This concern can significantly influence their decision to donate.
Incorrect Answers:
B: Fear of inferior medical care provided to donor. This is not a common concern as medical care for donors is typically of high quality.
C: Age and location of all possible organ recipients. While important, this is not a primary concern for families when deciding on organ donation.
D: Concern that donated organs will not be used. Families are generally more concerned about the impact on their loved one's appearance post-donation rather than the utilization of organs.
The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring th e patient from the stretcher to the bed. Prior to obtaining a cardiac output, which action is m ost important for the nurse to complete?
- A. Document a pulmonary artery catheter occlusion press ure.
- B. Zero reference the transducer system at the phlebostatic axis.
- C. Inflate the pulmonary artery catheter balloon with 1 m L air.
- D. Inject 10 mL of 0.9% normal saline into the proximal port.
Correct Answer: B
Rationale: The correct answer is B: Zero reference the transducer system at the phlebostatic axis. This is the most important action before obtaining a cardiac output because zero referencing ensures accurate pressure readings. The phlebostatic axis is the level of the atria when the patient is supine, and zeroing at this point minimizes errors in pressure measurements.
Choice A is incorrect because documenting a pulmonary artery catheter occlusion pressure is not the priority at this stage. Choice C is incorrect as inflating the balloon with air should be done after zero referencing. Choice D is incorrect as injecting normal saline into the port is not necessary before zero referencing.
What is the most common cause of a pulmonary embolus?
- A. An amniotic fluid embolus.
- B. A deep vein thrombosis from lower extremities.
- C. A fat embolus from a long bone fracture.
- D. Vegetation that dislodges from an infected central venous catheter.
Correct Answer: B
Rationale: The correct answer is B: A deep vein thrombosis from lower extremities. Deep vein thrombosis (DVT) is the most common cause of a pulmonary embolus as a blood clot can dislodge from the veins, travel to the lungs, and block blood flow. An amniotic fluid embolus (Choice A) occurs during childbirth and is rare as a cause of pulmonary embolism. A fat embolus (Choice C) typically occurs after a long bone fracture and is more likely to cause issues in the lungs. Vegetation from an infected central venous catheter (Choice D) can cause septic pulmonary embolism, but it is not as common as DVT.
Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide?
- A. Stimulate contraction of the uterus.
- B. Initiate the lactation process.
- C. Facilitate maternal-infant bonding.
- D. Prevent neonatal hypoglycemia.
Correct Answer: A
Rationale: The correct answer is A because breastfeeding helps stimulate the uterus to contract, which reduces the risk of postpartum hemorrhage in the mother. When the baby suckles at the breast, it triggers the release of oxytocin, a hormone that causes the uterus to contract. This contraction helps the uterus to return to its pre-pregnancy size and shape, promoting faster healing and reducing bleeding.
Choice B is incorrect because lactation initiation is a separate process that involves hormonal changes and milk production, which may not occur immediately after delivery. Choice C is incorrect as bonding can occur through various interactions beyond breastfeeding. Choice D is incorrect as neonatal hypoglycemia is primarily prevented by ensuring the baby receives adequate nutrition, which can also be achieved through other feeding methods besides breastfeeding.
Which treatment can be used to dissolve a thrombus that is lodged in the pulmonary artery?
- A. Aspirin
- B. Embolectomy
- C. Heparin
- D. Thrombolytics
Correct Answer: D
Rationale: The correct answer is D: Thrombolytics. Thrombolytics are medications that can dissolve blood clots, making them effective in treating a thrombus lodged in the pulmonary artery. They work by activating the body's natural clot-dissolving system. Aspirin (A) is an antiplatelet drug and may prevent further clot formation but cannot dissolve an existing thrombus. Embolectomy (B) is a surgical procedure to remove a clot and is invasive, usually reserved for cases where thrombolytics are contraindicated. Heparin (C) is an anticoagulant that prevents clot formation but does not dissolve existing clots like thrombolytics do.