Nokea
Which of the following devices is best suited to deliver 65 % oxygen to a patient who is spontaneously breathing?
- A. Face mask with non-rebreathing reservoir
- B. Low-flow nasal cannula
- C. Simple face mask
- D. Venturi mask
Correct Answer: D
Rationale: The Venturi mask is the best choice for delivering 65% oxygen because it allows precise oxygen concentration delivery through adjustable venturi valves. This device ensures consistent oxygen levels even during variations in patient breathing patterns. Face mask with non-rebreathing reservoir (A) delivers higher oxygen concentrations, low-flow nasal cannula (B) is not suitable for precise oxygen delivery, and simple face mask (C) may not provide the desired oxygen concentration.
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Ideally, by whom and when should an advance directive be developed?
- A. Family, if the patient is in critical condition.
- B. Patient as part of the hospital admission process.
- C. Patient before illness or impairment occurs.
- D. Patient’s healthcare surrogate.
Correct Answer: C
Rationale: Step-by-step rationale for choice C:
1. Advance directives should be made by the patient to reflect their wishes.
2. Developing it before illness ensures clarity and avoids confusion.
3. Patients may not be able to make informed decisions in critical conditions.
4. Family or surrogates may not accurately represent the patient's wishes.
Summary:
A - Family in critical condition may not know the patient's wishes.
B - Hospital admission process may be too late for clear decision-making.
D - Healthcare surrogate may not fully understand the patient's preferences.
What is true regarding pain and anxiety in the healthy individual? (Select all that apply.)
- A. They activate the sympathetic nervous system.
- B. They decrease stress levels.
- C. They help remove one from harm.
- D. They increase performance levels.
Correct Answer: A
Rationale: The correct answer is A because pain and anxiety trigger the sympathetic nervous system's fight-or-flight response, increasing heart rate, blood pressure, and stress hormones to prepare the body for potential danger. This physiological response helps the individual respond to perceived threats. Choices B, C, and D are incorrect because pain and anxiety typically increase stress levels, do not necessarily remove one from harm, and can hinder rather than enhance performance due to distraction and decreased focus.
The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document that indicates a successful outcome?
- A. Demonstrates adequate fluid intake and output.
- B. Verbalizes abdominal comfort without pressure.
- C. Drinks 240 mL of fluid five times during the shift.
- D. Voids at least 1000 mL between 7 am and 3 pm.
Correct Answer: C
Rationale: Step 1: The objective is for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm.
Step 2: Choice C states that the client drinks 240 mL of fluid five times during the shift, totaling 1200 mL (240 mL x 5) which exceeds the required amount.
Step 3: Therefore, choice C is the correct answer as it demonstrates successful achievement of the objective by ensuring the client has ingested enough fluid within the specified time frame.
Step 4: Choices A, B, and D are incorrect as they do not directly address the specific objective of fluid intake set for the client. Option A focuses on intake and output, option B relates to abdominal comfort, and option D is about voiding, none of which directly address the specified objective of fluid ingestion.
The nurse is caring for a patient who has an intra-aortic balloon pump in place. Which action should be included in the plan of care?
- A. Position the patient supine at all times.
- B. Avoid the use of anticoagulant medications.
- C. Measure the patient’s urinary output every hour.
- D. Provide a massive range of motion for all extremities.
Correct Answer: C
Rationale: The correct answer is C: Measure the patient’s urinary output every hour. This is crucial because monitoring urinary output is essential in assessing the patient’s renal function and the effectiveness of the intra-aortic balloon pump in improving cardiac output. Hourly measurement helps in early detection of any changes that may indicate complications.
A: Positioning the patient supine at all times is not necessary and can lead to complications.
B: Avoiding the use of anticoagulant medications is not appropriate as they are often necessary to prevent clot formation around the balloon pump.
D: Providing a massive range of motion for all extremities is not recommended for a patient with an intra-aortic balloon pump as it can dislodge the device or cause harm.
A critical care unit has decided to implement several measures designed to improve intradisciplinary and interdisciplinary collaboration. In addition to an expected improvement in patient outcomes, what is the most important effect that should resultf rom these measures?
- A. Identification of incompetent practitioners
- B. Improvement in manners on the unit
- C. Increased staff retention
- D. Less discussion in front of patients and families
Correct Answer: C
Rationale: Rationale:
- Improved collaboration enhances job satisfaction and reduces burnout, leading to increased staff retention.
- Higher staff retention promotes continuity of care, improves team dynamics, and enhances patient outcomes.
Summary:
- A: Not directly related to collaboration, more about performance evaluation.
- B: Manners may improve, but not the most important effect of collaboration.
- D: Collaboration involves open communication, so less discussion in front of patients is not a positive outcome.