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While waiting for cardiac transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. When planning care for this patient, the nurse should anticipate:
- A. Giving immunosuppressive medications.
- B. Preparing the patient for a permanent VAD.
- C. Teaching the patient the reason for complete bed rest.
- D. Monitoring the surgical incision for signs of infection.
Correct Answer: D
Rationale: The correct answer is D because monitoring the surgical incision for signs of infection is essential post-VAD implantation to prevent complications. This step is crucial in early identification and treatment of any potential infection, which can lead to serious outcomes.
A) Giving immunosuppressive medications is not typically required for VAD implantation, as the primary goal is to support cardiac function rather than prevent rejection.
B) Preparing the patient for a permanent VAD is premature, as the goal is often to bridge to transplantation or recovery, not permanent VAD placement.
C) Teaching the patient the reason for complete bed rest is not necessary for VAD implantation, as patients are typically encouraged to gradually increase activity levels under guidance.
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An ICU nurse has provided excellent care for a 6-year-old girl who had been admitted to the ICU for a head injury. The nurse was attentive not only to the needs of the patient but also went out of her way to care for the needs of the girls family. According to research, which of the following forms of recognition would the nurse value the most?
- A. A card from the girls family
- B. A plaque from the ICU physicians naming her as Nurse of the Year
- C. A letter of commendation from the hospitals administration
- D. A bouquet of flowers from her supervisor
Correct Answer: A
Rationale: Rationale: The correct answer is A: A card from the girl's family. The nurse would value this form of recognition the most because it directly reflects the impact of her care on the patient and her family. It is a personal, heartfelt gesture that acknowledges the nurse's compassion and dedication. A card from the family shows genuine appreciation and gratitude for the nurse's efforts, making it the most meaningful form of recognition.
Summary:
- Choice B: A plaque from the ICU physicians could be seen as a formal recognition but lacks the personal touch and direct impact of the nurse's care on the patient and family.
- Choice C: A letter of commendation from the hospital's administration is a professional acknowledgment but may not capture the emotional connection and impact that the nurse had on the family.
- Choice D: A bouquet of flowers from her supervisor is a nice gesture but does not necessarily reflect the specific impact of the nurse's care on the patient and family.
The nurse is caring for a patient diagnosed with hyperactivaebi rdb.ecloimri/tuemst . The nurse focuses interventions toward which priority need?
- A. Comfort
- B. Nourishment
- C. Safety
- D. Sedation
Correct Answer: C
Rationale: The correct answer is C: Safety. In hyperactive delirium, the patient may be agitated, disoriented, and at risk of harm. Safety is the priority to prevent falls or injury. Comfort (A) is important but secondary to safety in this case. Nourishment (B) can wait until safety is ensured. Sedation (D) may be considered but only after safety measures are in place.
After coronary artery bypass graft surgery a patient is transported to the surgical intensive care unit at noon and placed on mechanical ventilation. How sh ould the nurse interpret the patient’s initial arterial blood gas levels? pH 7.31 PaCO 48 mm Hg Bicarbonate 22 mEq/L PaO 115 mm Hg O saturation 99%
- A. Normal arterial blood gas levels with a high oxygen le vel
- B. Partly compensated respiratory acidosis, normal oxygen
- C. Uncompensated metabolic acidosis with high oxygen laebvirbe.lcso m/test
- D. Uncompensated respiratory acidosis; hyperoxygenated
Correct Answer: B
Rationale: The correct answer is B: Partly compensated respiratory acidosis, normal oxygen. The pH of 7.31 indicates acidosis, the PaCO2 of 48 mm Hg shows respiratory acidosis, and the bicarbonate level of 22 mEq/L is slightly elevated, indicating the kidneys are compensating. The PaO2 of 115 mm Hg and oxygen saturation of 99% are normal, ruling out hypoxemia. Therefore, the patient is experiencing partly compensated respiratory acidosis.
A: Normal arterial blood gas levels with a high oxygen level - Incorrect. The pH is low, indicating acidosis, which is not normal.
C: Uncompensated metabolic acidosis with high oxygen level - Incorrect. Metabolic acidosis would have a primary issue with bicarbonate levels, which is not the case here.
D: Uncompensated respiratory acidosis; hyperoxygenated - Incorrect. The oxygen levels are normal, ruling out hyperoxygenation.
Which of the following assists the critical care nurse in ensuring that care is appropriate and based on research?
- A. Clinical practice guidelines
- B. Computerized physician order entry
- C. Consulting with advanced practice nurses
- D. Implementing Joint Commission National Patient Safe ty Goals
Correct Answer: A
Rationale: The correct answer is A: Clinical practice guidelines. Clinical practice guidelines are evidence-based recommendations that assist nurses in providing appropriate care based on research. They outline best practices for specific patient populations or conditions, helping nurses make informed decisions.
Summary:
- B: Computerized physician order entry: While it may improve accuracy and efficiency, it does not specifically ensure care based on research.
- C: Consulting with advanced practice nurses: While collaboration is valuable, it does not guarantee care based on research.
- D: Implementing Joint Commission National Patient Safety Goals: Important for patient safety, but not directly related to ensuring care based on research.
The nurse is caring for a patient with a left radial arterial lianbierb, .caonmd/t eas tp ulmonary artery catheter inserted into the right subclavian vein. Which action by th e nurse best ensures the safety of the patient being monitored with invasive hemodynamic moni toring lines?
- A. Document all waveform values.
- B. Limit the pressure tubing length.
- C. Zero reference the system daily.
- D. Ensure alarm limits are turned on.
Correct Answer: C
Rationale: The correct answer is C: Zero reference the system daily. Zero referencing ensures accuracy and calibration of pressure monitoring system by setting the baseline pressure to zero. This is crucial to prevent inaccuracies in measurements. Choice A is important but doesn't directly address the accuracy of the monitoring system. Choice B may help in preventing errors but doesn't address the accuracy of pressure measurement. Choice D is important for alerting the nurse but doesn't directly relate to the accuracy of hemodynamic monitoring.