The patient has been admitted to the hospital with nausea and vomiting that started 5 days earlier. Blood pressure is 80/44 mm Hg and heart rate is 122 beats/min; the patient has not voided in 8 hours, and the bladder is not distended. The nurse anticipates a prescription for �stat� administration of- Skildor

Question 1 of 5

The patient has been admitted to the hospital with nausea and vomiting that started 5 days earlier. Blood pressure is 80/44 mm Hg and heart rate is 122 beats/min; the patient has not voided in 8 hours, and the bladder is not distended. The nurse anticipates a prescription for �stat� administration of

A. a blood transfusion. B. fluid replacement with 0.45% saline. C. infusion of an inotropic agent. D. an antiemetic.

Correct Answer: B

Rationale: The correct answer is B: fluid replacement with 0.45% saline. The patient's low blood pressure, tachycardia, and lack of urine output indicate hypovolemia. Fluid replacement with saline will help restore circulating volume, improve blood pressure, and support renal perfusion. A: Blood transfusion is not indicated as the primary issue is hypovolemia, not anemia. C: Inotropic agents are used to increase cardiac contractility but are not the initial treatment for hypovolemia. D: Antiemetics may help with symptoms but do not address the underlying issue of fluid loss and hypovolemia.

Question 2 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 3 of 5

Which of the following statements describes the core conc ept of the synergy model of practice?

A. All nurses must be certified in order to have the synerg y model implemented. B. Family members must be included in daily interdisciplaibnirabr.cyo mro/teusnt ds. C. Nurses and physicians must work collaboratively and synergistically to influence care. D. Unique needs of patients and their families influence nursing competencies.

Correct Answer: D

Rationale: Rationale: D is correct because the synergy model focuses on individualized care based on patients' unique needs. This model emphasizes tailoring nursing competencies to address these needs, promoting holistic care. A is incorrect as certification is not a requirement. B involves family inclusion but does not capture the core concept. C mentions collaboration but does not specifically address individualized care.

Question 4 of 5

A patient requires neuromuscular blockade (NMB) as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes which interventions? (Select all that apply.)

A. Administration of sedatives concurrently with neuromuscular blockade. B. Dangling the patient�s feet over the edge of the bed an d assisting the patient to sit up in a chair at least twice each day. C. Ensuring that deep vein thrombosis prophylaxis is initi ated. D. providing interventions for eye care, oral care, and skin care.

Correct Answer: C

Rationale: The correct answer is C: Ensuring that deep vein thrombosis prophylaxis is initiated. When a patient requires neuromuscular blockade for increased intracranial pressure, they are likely immobile, which increases the risk of deep vein thrombosis (DVT). Initiating DVT prophylaxis, such as compression stockings or anticoagulant therapy, helps prevent blood clot formation. Choice A is incorrect because sedatives can mask signs of neurologic deterioration in this patient population. Choice B is incorrect as it promotes activities that may increase intracranial pressure and could be harmful. Choice D, while important for overall patient care, is not directly related to the specific nursing interventions required for a patient receiving neuromuscular blockade for increased intracranial pressure.

Question 5 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.

Similar Questions

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The nurse is caring for a mechanically ventilated patient b eing monitored with a left radial arterial line. During the inspiratory phase of ventilation, th e nurse assesses a 20 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse?

Critical Care Nursing Questions and Answers PDF

Skildor

ATI RN