The nurse is caring for a patient who has sustained blunt trauma to the left flank area, and is evaluating the patient�s urinalysis results. The nurse should become concerned when- Skildor

Question 1 of 5

The nurse is caring for a patient who has sustained blunt trauma to the left flank area, and is evaluating the patient�s urinalysis results. The nurse should become concerned when

A. creatinine levels in the urine are similar to blood levels of creatinine. B. sodium and chloride are found in the urine. C. urine uric acid levels have the same values as serum levels. D. red blood cells and albumin are found in the urine.

Correct Answer: D

Rationale: The correct answer is D because the presence of red blood cells and albumin in the urine indicates possible kidney damage from the blunt trauma. This is concerning as it may suggest renal injury or dysfunction. A: Creatinine levels in the urine being similar to blood levels is normal as creatinine is filtered by the kidneys. B: Sodium and chloride being present in the urine is expected as they are components of urine. C: Urine uric acid levels matching serum levels is common as uric acid is excreted by the kidneys. In summary, the presence of red blood cells and albumin in the urine is abnormal and indicates potential kidney damage, making it the correct answer.

Question 2 of 5

Sleep often is disrupted for critically ill patients. Which nu rsing intervention is most appropriate to promote sleep and rest?

A. Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals. B. Encourage family members to talk with the patient wh enever they are present in the room. C. Keep the television on to provide �white� noise and di straction. D. Leave the lights on in the room so that the patient is no t frightened of his or her surroundings.

Correct Answer: A

Rationale: The correct answer is A: Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals. This is the most appropriate intervention as medication timings can significantly impact sleep patterns of critically ill patients. Adjusting medication times can help synchronize rest periods, promoting uninterrupted sleep. Choice B is incorrect as encouraging constant conversation can disrupt sleep. Choice C is incorrect as the television noise can be stimulating and hinder rest. Choice D is incorrect as leaving the lights on can disrupt the patient's circadian rhythm and negatively impact sleep quality.

Question 3 of 5

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.

Question 4 of 5

When caring for a patient with a pulmonary artery (PA) pressure catheter, the nurse observes that the PA waveform indicates that the catheter is in the wedged position. Which action should the nurse take next?

A. Zero balance the transducer. B. Activate the fast flush system. C. Notify the health care provider. D. Deflate and reinflate the PA balloon.

Correct Answer: C

Rationale: The correct answer is C: Notify the health care provider. When the PA waveform indicates the catheter is in the wedged position, it means the catheter tip is in the pulmonary artery, potentially causing complications. The nurse should notify the healthcare provider immediately to assess and reposition the catheter to prevent further issues. Zero balancing the transducer (A) or activating the fast flush system (B) are not appropriate actions for this situation. Deflating and reinflating the PA balloon (D) could exacerbate the issue and should only be done under the guidance of the healthcare provider.

Question 5 of 5

A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam 1 to 2 mg IV as needed (prn). The patient has received no lorazepam during this course of illness. What is the most appropriate nursing intearbvirbe.ncotmio/tnes tt o control agitation?

A. Administer fentanyl (Duragesic) 25 mg IV bolus. B. Administer midazolam 2 mg IV now. C. Increase the rate of the morphine infusion by 50%. D. Request an order for a paralytic agent.

Correct Answer: B

Rationale: Step-by-step rationale for why choice B is correct: 1. Midazolam is a benzodiazepine used for sedation and anxiolysis. 2. It acts quickly and has a short duration of action, suitable for acute agitation. 3. Lorazepam (also a benzodiazepine) is in the same drug class, ensuring compatibility. 4. Lorazepam is specifically ordered for this patient, indicating its appropriateness. 5. Administering midazolam addresses the patient's agitation efficiently and safely. Summary of why other choices are incorrect: A: Fentanyl is an opioid analgesic, not ideal for managing agitation. C: Increasing morphine infusion can exacerbate sedation or respiratory depression. D: Paralytic agents are used for neuromuscular blockade, not agitation control.

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A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam 1 to 2 mg IV as needed (prn). The patient has received no lorazepam during this course of illness. What is the most appropriate nursing intearbvirbe.ncotmio/tnes tt o control agitation?

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Her urine output for the past 2 hours totaled only 40 mL. She arrived from s urgery to repair an aortic aneurysm 4 hours ago and remains on mechanical ventilation. In the past 2 hours, her heart rate has increased from 80 to 100 beats per minute and he r blood pressure has decreased from 128/82 to 100/70 mm Hg. She is being given an infusaiboirnb .coofm n/toesrtm al saline at 100 mL per hour. Her right atrial pressure through the subclavian cen tral line is low at 3 mm Hg. Her urine is concentrated. Her BUN and creatinine levels have been stable and in normal range. Her abdominal dressing is dry with no indication of bleeding. My assessment suggests that Mrs. P. is hypovolemic and I would like you to consider in creasing her fluids or giving her a fluid challenge. Using the SBAR model for communication, the information the nurse gives about the patient�s history and vital signs is appropriate fo r what part of the model?

Critical Care Nursing Questions and Answers PDF

Skildor

ATI RN