Nokea
While family members are visiting, a patient has a cardiac arrest and is being resuscitated. Which of the following actions by the nurse is best?
- A. Ask family members if they wish to remain in the room during the resuscitation.
- B. Explain to family members that watching the resuscitation will be very stressful.
- C. Assign a staff member to wait with family members just outside the patient room.
- D. Escort family members quickly out of the patient room and then remain with them.
Correct Answer: A
Rationale: Research indicates that family members want the option of remaining in the room during procedures such as CPR and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient.
You may also like to solve these questions
The nurse is caring for a patient who has acute pancreatitis and the mixed venous oxygen saturation (SvO2) is decreasing. Which of the following parameters should the nurse assess to determine the possible cause of the decreased SvO2?
- A. Weight
- B. Amylase
- C. Temperature
- D. Urinary output
Correct Answer: C
Rationale: Elevated temperature increases metabolic demands and oxygen use by tissues, resulting in a drop in oxygen saturation of mixed venous blood. Information about the patient's weight, urinary output, and amylase will not help in determining the cause of the patient's drop in SvO2.
The nurse is caring for a patient with a head injury intubated and placed on a mechanical ventilator. When monitoring the patient, which of the following findings should the nurse report to the health care provider?
- A. Oxygen saturation of 94%.
- B. Respirations of 18 breaths/minute.
- C. Green nasogastric tube drainage.
- D. Increased jugular venous distention.
Correct Answer: D
Rationale: Increases in JVD in a patient with head injury may indicate an increase in intra-cranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 18, saturation of 94%, and green nasogastric tube drainage are normal.
The nurse is caring for a patient following surgery whose central venous pressure (CVP) monitor indicates low pressures. Which of the following actions should the nurse anticipate implementing?
- A. Increase the IV fluid infusion rate.
- B. Administer IV diuretic medications.
- C. Elevate the head of the patient's bed to 45 degrees.
- D. Document the CVP and continue to monitor.
Correct Answer: A
Rationale: A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head may decrease cerebral perfusion. Documentation and continued monitoring is an inadequate response to the low CVP.
The nurse is caring for a patient with heart failure requiring a ventricular assist device (VAD) implanted and is waiting for cardiac transplantation. Which of the following actions should the nurse include in the plan of care?
- A. Administer of immuno-suppressive medications.
- B. Monitor the surgical incision for signs of infection.
- C. Teach the patient the reason for continuous bed rest.
- D. Prepare the patient to have the VAD in place permanently.
Correct Answer: B
Rationale: The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immuno-suppression is not necessary for nonbiological devices like the VAD.
The nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which of the following patient assessments indicates that the weaning protocol should be discontinued?
- A. The patient heart rate is 98 beats/minute.
- B. The patient's oxygen saturation is 93%.
- C. The patient respiratory rate is 32 breaths/minute.
- D. The patient's spontaneous tidal volume is 500 mL.
Correct Answer: C
Rationale: A respiratory rate of 32 breaths/minute indicates respiratory distress and suggests that the patient is not tolerating the weaning process, necessitating discontinuation of the weaning protocol. A heart rate of 98 beats/minute, oxygen saturation of 93%, and spontaneous tidal volume of 500 mL are within acceptable ranges for weaning.