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Which statement is true regarding venous thromboembolisambir b(.VcoTm/Ete)s ta nd pulmonary embolus (PE)?
- A. PE should be suspected in any patient who has unexpla ined cardiorespiratory complaints and risk factors for VTE.
- B. Bradycardia and hyperventilation are classic symptom s of PE.
- C. Dyspnea, chest pain, and hemoptysis occur in nearly a ll patients with PE.
- D. Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis.
Correct Answer: A
Rationale: The correct answer is A because PE should be suspected in patients with unexplained cardiorespiratory complaints and risk factors for VTE. This is important because PE can present with nonspecific symptoms, making it crucial to consider it in the differential diagnosis.
Explanation:
1. PE can present with various symptoms, including dyspnea, chest pain, and hemoptysis, but these are not present in all patients.
2. Bradycardia and hyperventilation are not classic symptoms of PE, as it can present with tachycardia and other respiratory findings.
3. Critically ill patients are actually at higher risk for VTE and PE, so prophylaxis is typically recommended.
In summary, choice A is correct because it emphasizes the importance of considering PE in patients with cardiorespiratory complaints and risk factors for VTE, while the other choices contain inaccuracies or incomplete information.
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The emergency department (ED) nurse is initiating therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)?
- A. Continuously monitor heart rhythm.
- B. Check neurologic status every 2 hours.
- C. Place cooling blankets above and below the patient.
- D. Give acetaminophen (Tylenol) 650 mg per nasogastric tube.
Correct Answer: D
Rationale: Correct Answer: D - Give acetaminophen (Tylenol) 650 mg per nasogastric tube.
Rationale: LPNs/LVNs are trained to administer medications, including oral and nasogastric routes. Giving acetaminophen via nasogastric tube is within their scope of practice. LPNs/LVNs should have the knowledge and skills to safely administer this medication as part of the hypothermia protocol.
Summary of other choices:
A: Continuously monitor heart rhythm - This requires specialized training and skills typically within the scope of registered nurses or cardiac monitoring technicians.
B: Check neurologic status every 2 hours - Assessing neurologic status requires critical thinking and clinical judgment, which are typically responsibilities of registered nurses.
C: Place cooling blankets above and below the patient - Positioning and managing cooling devices may require specific training and should be done under the supervision of a registered nurse.
Which of the following patients is at the greatest risk of developing acute kidney injury? A patient who
- A. has been on aminoglycosides for the past 6 days
- B. has a history of controlled hypertension with a blood pressure of 138/88 mm Hg
- C. was discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks
- D. has a history of fluid overload as a result of heart failure
Correct Answer: D
Rationale: The correct answer is D because a patient with a history of fluid overload due to heart failure is at the greatest risk of developing acute kidney injury. Heart failure can lead to decreased kidney perfusion causing acute kidney injury. In this scenario, the patient's fluid overload exacerbates the situation, further compromising kidney function.
Choice A is incorrect as aminoglycosides can cause kidney injury but the duration of 6 days is less concerning compared to chronic fluid overload from heart failure in choice D. Choice B is incorrect because controlled hypertension does not directly increase the risk of acute kidney injury. Choice C is incorrect as the patient being discharged 2 weeks earlier after aminoglycoside therapy does not necessarily indicate a higher risk compared to chronic fluid overload.
The most common cause of acute kidney injury in critically ill patients is
- A. sepsis.
- B. fluid overload.
- C. medications.
- D. hemodynamic instability.
Correct Answer: A
Rationale: The correct answer is A: sepsis. Sepsis is the most common cause of acute kidney injury in critically ill patients due to the systemic inflammatory response causing renal hypoperfusion. Sepsis leads to a decrease in renal blood flow, resulting in acute kidney injury. Fluid overload (B) can contribute to renal dysfunction but is not the primary cause in critically ill patients. Medications (C) can cause kidney injury, but sepsis is more prevalent. Hemodynamic instability (D) is a consequence of sepsis and can lead to acute kidney injury, making it an indirect cause.
The critical care environment is stressful to the patient. Which interventions assist in reducing this stress? (Select all that apply.)
- A. Adjust lighting to promote normal sleep-wake cycles.
- B. Provide clocks, calendars, and personal photos in the p atient’s room.
- C. Talk to the patient about other patients you are caring for on the unit.
- D. Tell the patient the day and time when you are providi ng routine nursing interventions.
Correct Answer: A
Rationale: Correct Answer: A. Adjust lighting to promote normal sleep-wake cycles.
Rationale:
1. Adjusting lighting can help regulate the patient's circadian rhythm, promoting better sleep and reducing stress.
2. Normal sleep-wake cycles are crucial for overall well-being and healing in a critical care setting.
3. Proper lighting can also create a more calming environment for the patient.
Summary of Incorrect Choices:
B. Providing clocks, calendars, and personal photos can be overwhelming for a stressed patient.
C. Talking about other patients may increase anxiety and breach patient confidentiality.
D. Telling the day and time of routine interventions may disrupt the patient's sense of time and add to stress.
The nurse is assessing the patient’s pain using the Critical Care Pain Observation Tool (CPOT). Which of the following assessments would indicate the greatest likelihood of pain and need for nursing intervention?
- A. Absence of vocal sounds
- B. Fighting the ventilator
- C. Moving legs in bed
- D. Relaxed muscles in upper extremities
Correct Answer: B
Rationale: The correct answer is B: Fighting the ventilator. This behavior indicates the patient is experiencing discomfort and struggling against the ventilator, suggesting a high likelihood of pain. The CPOT assesses pain through behaviors like grimacing, vocalization, and muscle tension, which are all present when a patient is fighting the ventilator. Absence of vocal sounds (Choice A) does not necessarily indicate pain as some patients may be silent even when in pain. Moving legs in bed (Choice C) could be due to restlessness rather than pain. Relaxed muscles in upper extremities (Choice D) do not reflect pain as the CPOT focuses on behaviors indicating discomfort.