Nokea
While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic intervention?
- A. Diuretics
- B. Intravenous fluids
- C. Negative inotropic agents
- D. Vasopressors
Correct Answer: B
Rationale: The correct answer is B: Intravenous fluids. In the scenario of a small bowel obstruction, a PAOP of 1 mm Hg indicates hypovolemia requiring fluid resuscitation to improve cardiac output and tissue perfusion. The low urine output suggests inadequate renal perfusion, further supporting the need for fluids. Diuretics (choice A) would worsen the hypovolemia. Negative inotropic agents (choice C) decrease cardiac contractility, which is not indicated in this scenario. Vasopressors (choice D) are used for hypotension, not for hypovolemia. Therefore, the most appropriate intervention is to administer intravenous fluids to address the hypovolemia and improve tissue perfusion.
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The nurse is caring for an elderly patient who was admitted with renal insufficiency. An expected laboratory finding for this patient may be
- A. an increased glomerular filtration rate (GFR).
- B. a normal serum creatinine level.
- C. increased ability to excrete drugs.
- D. hypokalemia.
Correct Answer: B
Rationale: The correct answer is B: a normal serum creatinine level. In renal insufficiency, the kidneys are not able to filter waste products effectively, leading to an increase in serum creatinine levels. This is a common indicator of renal dysfunction.
A: An increased GFR would not be expected in renal insufficiency, as it signifies improved kidney function.
C: Increased ability to excrete drugs is not a typical finding in renal insufficiency, as impaired kidney function can lead to drug accumulation.
D: Hypokalemia is not directly related to renal insufficiency. It is more commonly associated with factors like diuretic use or gastrointestinal losses.
Which of the following are accepted nonpharmacological approaches to managing pain and/or anxiety in critically ill patients? (Select all that apply.)
- A. Environmental manipulation
- B. Explanations of monitoring equipment
- C. Guided imagery
- D. Music therapy
Correct Answer: A
Rationale: Step 1: Environmental manipulation involves adjusting factors like lighting, noise levels, and room temperature to create a soothing environment, which can help reduce pain and anxiety.
Step 2: By controlling the physical surroundings, patients may feel more comfortable and relaxed, leading to improved pain management and reduced anxiety levels.
Step 3: Explanations of monitoring equipment and guided imagery are not directly related to environmental changes that can impact pain and anxiety.
Step 4: Music therapy, while beneficial for some patients, is not categorized as environmental manipulation.
The nurse cares for a patient with lung cancer in a home hospice program. Which action by the nurse is most appropriate?
- A. Discuss cancer risk factors and appropriate lifestyle modifications.
- B. Encourage the patient to discuss past life events and their meaning.
- C. Teach the patient about the purpose of chemotherapy and radiation.
- D. Accomplish a thorough head-to-toe assessment several times a week.
Correct Answer: B
Rationale: The correct answer is B because in a home hospice program, it is essential for the nurse to provide holistic care that includes addressing the patient's emotional and psychological needs. Encouraging the patient to discuss past life events and their meaning can help them process emotions, find closure, and improve their quality of life. This approach aligns with the principles of palliative care, which focus on enhancing comfort and well-being.
Choice A is incorrect because discussing cancer risk factors and lifestyle modifications may not be relevant or beneficial for a patient in a hospice program. Choice C is incorrect because chemotherapy and radiation are typically not part of hospice care, which focuses on comfort rather than curative treatments. Choice D is incorrect because a thorough head-to-toe assessment multiple times a week may not be necessary or appropriate for a patient in a hospice program.
The VALUE mnemonic is a helpful strategy to enhance communication with family members of critically ill patients. Which of the following statements describes a VALUE strategy?
- A. View the family as guests on the unit.
- B. Acknowledge family emotions.
- C. Learn as much as you can about family structure and f unction.
- D. Use a trained interpreter if the family does not speak English.
Correct Answer: B
Rationale: The correct answer is B: Acknowledge family emotions. This is a key component of the VALUE strategy as it emphasizes empathy and understanding towards the emotions that family members may be experiencing during a difficult time. By acknowledging their emotions, healthcare providers can build trust and establish a supportive relationship with the family.
Choice A is incorrect because the VALUE strategy focuses on treating family members as integral members of the care team, not just as guests. Choice C is incorrect as learning about family structure and function is important but not specifically part of the VALUE strategy. Choice D is incorrect as using a trained interpreter is important for effective communication but is not specific to the VALUE mnemonic.
Which of the following are components of the Institute for Healthcare Improvement’s (IHI’s) ventilator bundle? (Select all that apply.)
- A. Interrupt sedation each day to assess readiness to extub aa bit re b.. c om/test
- B. Maintain head of bed at least 30 degrees elevation.
- C. Provide deep vein thrombosis prophylaxis.
- D. Provide prophylaxis for peptic ulcer disease.
Correct Answer: A
Rationale: The correct answer is A because interrupting sedation daily to assess readiness to extubate is a key component of IHI's ventilator bundle to prevent ventilator-associated pneumonia. This practice helps prevent over-sedation, reduce the duration of mechanical ventilation, and decrease the risk of complications. The other choices, B, C, and D, are incorrect as they are not specific components of the IHI's ventilator bundle. Maintaining head of bed elevation, providing deep vein thrombosis prophylaxis, and prophylaxis for peptic ulcer disease are important aspects of critical care but are not directly related to the ventilator bundle protocol outlined by IHI.