Complex Adult Health Exam 1Complex Adult Health Exam 1

After the insertion of a permanent pacemaker, patient education is crucial for ensuring safety and proper care. Here’s a breakdown of each option: A: Do not have a microwave oven in the home.

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Rationale: This is not generally required. Modern microwaves do not typically interfere with pacemakers.

B: Avoid walking through antitheft devices in the doorways of stores.

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Rationale: True. These devices may cause interference with the pacemaker, so patients should avoid standing too close or walking through them.

C: Handheld metal detectors should not be placed directly over the pacemaker.

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Rationale: True. Handheld metal detectors can interfere with pacemakers, and they should be kept away from the device.

D: Do not drive until cleared by the healthcare provider.

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Clearer pictures at the Bottom of the file

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Rationale: True. Patients are often advised to refrain from driving for a period after pacemaker insertion until cleared by their healthcare provider to ensure their safety and the safety of others.

E: Count your pulse for 1 minute each morning.

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Rationale: While this is generally a good practice, it might not be a core requirement specifically after pacemaker installation. However, monitoring pulse can help detect any irregularities.

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B

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C

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D

These options are crucial for safety and precaution after the insertion of a pacemaker.

In this scenario, the nurse must ensure specific safety protocols before defibrillating a client. Here's a breakdown of the options: A: Ensure the defibrillator is in synchronous mode.

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Rationale: This is important for synchronized cardioversion but not necessary for defibrillation (which is asynchronous). Thus, this is not the appropriate action for defibrillation.

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Recommended Answers:

B: Administer a sedative before giving the shock.

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Rationale: Administering a sedative is generally not a standard practice immediately before defibrillation. Patients usually require sedation for cardioversion rather than defibrillation unless the patient's condition indicates otherwise.

C: Confirm that everyone is clear of contact with the client and bed.

Rationale: This is essential. Before delivering a shock, it's crucial to ensure that no one is in contact with the client or the bed to prevent accidental injury from the shock.

D: Stop CPR when pads are being placed on the client’s chest.

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Rationale: CPR should be paused only right before the shock is delivered, not while placing the pads. Thus, this option is not correct as well.

Recommended Answer: •

C (Confirm that everyone is clear of contact with the client and bed).

This step ensures safety before delivering a defibrillation shock.

In this scenario, the nurse must prioritize which finding to address first in the emergency department. Let's analyze each option: A: Generalized diaphoresis

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Rationale: While diaphoresis can indicate distress or a serious condition, it's not immediately life-threatening by itself.

B: Blood pressure of 104/63 mmHg •

Rationale: This indicates a slightly low blood pressure, which may require monitoring but may not be the priority unless accompanied by other symptoms.

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Rationale: Cyanosis is a critical finding, indicating that the body is not receiving enough oxygen. This is a priority because it suggests potential respiratory or cardiac compromise.

D: Client rates pain 9 out of 10 on a 0-10 scale •

Rationale: Severe pain should always be addressed, but it does not indicate immediate life-threatening conditions like cyanosis does.

Recommended Answer: •

C (Cyanosis to the skin and mucous membranes).

This finding poses the most urgent risk to the patient's overall health and must be addressed first.

To calculate the infusion rate for administering heparin sodium, we can follow these steps: Given:

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C: Cyanosis to the skin and mucous membranes

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Desired dosage: 800 units/hour

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Concentration of the solution: 20,000 units/250 mL

Calculation Steps: 1. Determine the concentration in units per mL: Concentration=20,000 units250 mL=80 units/mLConcentration=250 mL20,000 units =80 units/mL

Infusion rate (mL/hour)=800 units/hour80 units/mL=10 mL/hourInfusion rate (mL/h our)=80 units/mL800 units/hour=10 mL/hour Conclusion: •

The nurse will set the infusion rate at 10 mL/hour.

Answer: 1. 10 (mL/hour).

In this scenario, the client is intubated, receiving mechanical ventilation, and displaying signs of anxiety and distress. Let's analyze the options: A: Try to identify the cause of the distress and provide reassurance.

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2. Determine the infusion rate in mL/hour needed to achieve the desired dosage of 800 units/hour:

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Rationale: While understanding the cause of distress is important, this approach may not be effective in an emergency situation. The client is in a vulnerable state and immediate interventions can help alleviate anxiety.

B: Increase the rate for the ordered propofol infusion.

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Rationale: If the client is anxious, adjusting the propofol rate could help sedate them. However, it should be done cautiously and according to the healthcare provider's orders. This could be a reasonable option if propofol is indicated.

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Rationale: Administering midazolam can quickly provide sedation and relieve anxiety. This is a common approach for managing anxiety in intubated patients.

D: Manually ventilate the client with a bag-valve-mask device.

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Rationale: This option is typically used if the patient's ventilation is inadequate.

If the client is in distress but not showing signs of inadequate ventilation, this may not be the first course of action.

Recommended Action: •

C (Sedate the client with the ordered midazolam IV push).

This addresses the anxiety directly and can help stabilize the client while ensuring adequate sedation.

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C: Sedate the client with the ordered midazolam IV push.

RNstudentresources.com In this scenario, the client suddenly slumps over and stops breathing, and the telemetry monitor shows a heart rate of 202 with no detectable pulse. Here’s a breakdown of the appropriate nursing actions: Possible Actions 1. Prepare for synchronized cardioversion: o

Rationale: This is used for unstable tachycardia but is not appropriate here as the client is unresponsive and without a pulse.

2. Lie the client flat on their back: o

Rationale: While necessary for certain interventions, this is not adequate action in an emergency where the client is pulseless.

3. Begin cardiopulmonary resuscitation (CPR): o

Rationale: Immediate CPR is crucial when a client is unresponsive and has no pulse. It helps maintain circulation until advanced interventions can be applied.

o

Rationale: If the rhythm is shockable, this might be necessary, but CPR should be initiated first.

5. Activate a code response: o

Rationale: This is crucial in a cardiac emergency to ensure that advanced medical help arrives promptly.

Recommended Actions: •

1. Activate a code response.

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2. Begin cardiopulmonary resuscitation (CPR).

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3. Prepare for defibrillation if the rhythm is deemed shockable after initial CPR efforts.

Summary: In the event of cardiac arrest with no pulse, the priority is to activate emergency response and initiate CPR immediately. These actions can help improve the chances of survival until further medical help arrives.

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4. Prepare for defibrillation:

Given: •

Desired dose: 25 mcg

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Available concentration: 100 mcg/mL

Calculation Steps: 1. Set up the ratio: Desired Dose (mcg)=Available Concentration (mcg/mL)×Volume (mL)Desired Dose (m cg)=Available Concentration (mcg/mL)×Volume (mL) 2. Rearrange the equation to find the volume: Volume (mL)=Desired Dose (mcg)Available Concentration (mcg/mL)Volume (mL)=Ava ilable Concentration (mcg/mL)Desired Dose (mcg) 3. Substitute the known values: Volume (mL)=25 mcg100 mcg/mL=0.25 mLVolume (mL)=100 mcg/mL25 mcg =0.25 mL Final Result: •

Administer: 0.3 mL (rounded to the nearest tenth).

Answer: 1. 0.3 mL.

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To calculate how many mL of fentanyl to administer, we can follow these steps:

After a chest tube insertion for a client with a pneumothorax, the nurse should prioritize actions based on the immediate needs of the client and the potential complications.

Here’s a breakdown of the options: A: Evaluate for subcutaneous emphysema at the site.

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Rationale: This is important and should be assessed, but it may not be the first priority immediately after the procedure.

B: Ask the client if they need pain medication.

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Rationale: While managing pain is important, ensuring the tube is functioning properly and assessing respiratory status takes precedence.

C: Request a portable chest x-ray to check the tube.

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Rationale: This is crucial to confirm proper placement and functionality of the chest tube, especially after insertion.

D: Check the client's breathing and lung sounds.

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Rationale: This action is vital to assess the client's respiratory status and ensure the chest tube is effectively allowing re-expansion of the lung.

Recommended Action: •

D (Check the client's breathing and lung sounds).

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This calculation ensures the accurate and safe administration of fentanyl.

In the scenario where a client on mechanical ventilation becomes agitated, let's evaluate the options available to the nurse: A: Ask the family to leave the room to allow the client to rest.

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Rationale: While reducing stimuli can help, asking family members to leave may not address the client's immediate need for communication and support, which might contribute to their agitation.

B: Assess the client's RASS score and increase the sedation as prescribed.

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Rationale: This is a good course of action. By assessing the RASS (Richmond Agitation-Sedation Scale), the nurse can determine the appropriate sedation level for the client and adjust as necessary. However, increasing sedation should be done carefully based on the client's condition.

C: Provide a white board so the client can write their request.

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Rationale: This could help facilitate communication, but if the client is agitated and unable to focus, it may not fully address their immediate need for reassurance and sedative support.

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This is the priority action to ensure that the patient is ventilating properly and that the chest tube is functioning as intended before moving on to other assessments or interventions.

D: Increase the client's level of sedation.

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Rationale: While increasing sedation may be beneficial, this should be done based on a proper assessment rather than as an automatic response.

Recommended Action: •

B (Assess the client's RASS score and increase the sedation as prescribed).

To reduce the risk of ventilator-associated pneumonia (VAP) in a client on mechanical ventilation, let's analyze each option presented: A: Initiate early exercise and mobilization.

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Rationale: Early mobilization is proven to reduce the risk of VAP by improving lung function and promoting better respiratory mechanics. It can prevent complications associated with prolonged immobility.

B: Keep the client under deep sedation.

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Rationale: Keeping a patient deeply sedated can increase the risk of pneumonia as it may reduce their ability to cough and clear secretions effectively. This option is not beneficial for preventing VAP.

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This option allows for a more tailored approach to managing the client’s agitation while ensuring that their safety and comfort are prioritized.

C: Routinely change the ventilator circuit tubing.

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Rationale: Routine changes of ventilator circuits are generally not recommended because they can actually introduce bacteria and increase the risk of infection. This is not an effective way to prevent VAP.

D: Provide oral care with sterile saline solution.

Rationale: Oral care is important for VAP prevention, but using saline specifically is not the preferred method. Instead, using an antiseptic mouthwash can be more effective.

Recommended Action: •

A (Initiate early exercise and mobilization).

This is the best option for preventing VAP as it addresses patient mobility and lung function directly.

In this scenario where a client on mechanical ventilation becomes agitated, let's assess the options provided for the nurse's response.

A: Ask the family to leave the room to allow the client to rest.

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Rationale: While reducing distractions can be helpful, family presence can provide comfort and reassurance. Removing them might increase the client's anxiety.

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B: Assess the client's RASS score and increase the sedation as prescribed.

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Rationale: This option is appropriate as it involves assessing the client's current sedation level. Adjusting sedation based on a proper assessment helps ensure the client's comfort and safety without over-sedating.

C: Provide a white board so the client can write their request.

Rationale: A whiteboard may facilitate communication, but if the client is agitated, they might not be able to focus or effectively use it, making this option less effective in addressing immediate needs.

D: Increase the client's level of sedation.

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Rationale: This option can provide quick relief, but sedation should be adjusted based on a proper assessment rather than assumed or done without evaluation.

Recommended Action: •

B (Assess the client's RASS score and increase the sedation as prescribed).

This approach ensures a careful and individualized response to the client's agitation while maintaining safety and comfort. Assessing first allows for a tailored intervention based on the client's current condition.

To reduce the risk of ventilator-associated pneumonia (VAP) in a client on mechanical ventilation, let's evaluate the options: A: Initiate early exercise and mobilization.

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Rationale: Early mobilization has been shown to improve lung function and reduce the risk of VAP. It helps maintain respiratory muscle strength and promotes better overall health outcomes in mechanically ventilated patients. This is a recommended practice in VAP prevention.

B: Keep the client under deep sedation.

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Rationale: Maintaining deep sedation increases the risk for VAP, as it can impair the patient’s ability to cough and clear secretions. This option is not effective for preventing pneumonia.

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Rationale: Routine changes of the ventilator circuit can actually cause contamination and increase the risk for infection. Current guidelines recommend against doing this routinely for VAP prevention.

D: Provide oral care with sterile saline solution.

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Rationale: While oral care is important for preventing VAP, using sterile saline is not the recommended method. Antiseptic oral care solutions, such as chlorhexidine, are more effective in reducing the risk of VAP.

Recommended Action: •

A (Initiate early exercise and mobilization).

This approach is effective for reducing the risk of VAP and supporting overall respiratory health in critically ill patients on mechanical ventilation.

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C: Routinely change the ventilator circuit tubing.

A: Small amount of subcutaneous emphysema at the insertion site.

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Rationale: A small amount of subcutaneous emphysema can occur postprocedure and is often not immediately concerning unless it increases in size or causes significant symptoms.

B: Intermittent bubbling in the water seal chamber.

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Rationale: Intermittent bubbling is usually expected and indicates that air is being removed from the pleural space. This does not typically require immediate intervention.

C: Continuous bubbling in the suction-control chamber.

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Rationale: Continuous bubbling in the suction-control chamber may indicate an air leak. This observation needs further evaluation, but it doesn't necessarily warrant immediate intervention unless significant clinical signs are present.

D: 600 mL of blood in the collection chamber in the last two hours.

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Rationale: This represents significant drainage, which is concerning in a client with hemopneumothorax. It may indicate bleeding; therefore, this finding should be reported immediately to the healthcare provider.

Recommended Action:

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In the scenario where a nurse is caring for a client with hemopneumothorax being treated with a chest tube, the following observations are presented:

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D (600 mL of blood in the collection chamber in the last two hours).

The ABCDEF bundle is a set of evidence-based practices aimed at improving patient outcomes in intensive care settings. Let's evaluate the options provided regarding the purpose of this bundle: A: This bundle includes the nurse consulting the wound/ostomy nurse when needed.

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Rationale: While consulting specialized nurses may be part of comprehensive care, this specific action is not a primary focus of the ABCDEF bundle.

B: This bundle assesses the oxygenation status of the client on mechanical ventilation.

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Rationale: Monitoring oxygenation is a critical aspect of care in the ICU, but it's not the main defining purpose of the ABCDEF bundle.

C: This bundle ensures adequate nutrition for the client within an intensive care unit.

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This option indicates a potentially serious complication and is the priority observation that requires immediate attention from the healthcare provider. Monitoring for excessive bleeding is critical in this context.

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Rationale: While nutrition is important in the ICU, ensuring adequate nutrition is not the central purpose of the ABCDEF bundle.

D: This bundle sets standards for the management of clients with complex health issues.

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Rationale: The ABCDEF bundle is designed specifically to improve outcomes for ICU patients by focusing on sedation, delirium prevention, early mobility, and family engagement, among other aspects. This option aligns with the broader goals of the bundle.

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D (This bundle sets standards for the management of clients with complex health issues).

This choice reflects the overall purpose of the ABCDEF bundle, which is to provide a standardized approach to managing critically ill patients effectively.

In this scenario involving a client with peripheral artery disease (PAD), let’s evaluate the actions of the unlicensed assistive personnel (UAP) to determine what requires nursing intervention: A: The UAP elevates the client's legs on pillows.

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Rationale: Elevating the legs can potentially reduce blood flow to the lower extremities in patients with PAD, worsening their condition. This action might require intervention by the nurse if it is not aligned with care protocols.

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Recommended Answer:

B: The UAP reminds the client to uncross their legs.

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Rationale: This is a beneficial action as crossing the legs can restrict circulation, which is especially important for clients with PAD. This action supports better blood flow.

C: The UAP applies moisturizer to the client's legs.

Rationale: Applying moisturizer is generally helpful for skin integrity, but it must be done cautiously in clients with PAD to avoid potential skin irritations.

However, it is generally acceptable.

D: The UAP ambulates the client to the bathroom.

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Rationale: Ambulating the client is important for circulation and overall mobility. As long as the client is stable, this action is usually appropriate and does not require intervention.

Recommended Action: •

A (The UAP elevates the client's legs on pillows).

This option poses the most risk to the client with peripheral artery disease, as it could compromise circulation further and potentially lead to more significant complications.

Therefore, this action warrants intervention by the nurse.

When assessing potential organ donors from the given options, the nurse needs to consider the health status and medical history of each client. Here's the evaluation: A: A client who overdosed on intravenous heroin.

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Rationale: Substance abuse may affect organ viability. However, it might still depend on the duration of the overdose, the client's overall health, and if the organs are still viable at the time of death.

B: A client with systemic lupus erythematosus (SLE).

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Rationale: SLE can affect various organs and may lead to complications that decrease organ viability. This may also exclude them from being a donor in many cases.

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Rationale: This client may have sustained traumatic injuries, but if declared brain dead and organs are otherwise healthy, they could potentially be a good candidate for organ donation.

D: A client with amyotrophic lateral sclerosis (ALS).

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Rationale: ALS is a progressive neurodegenerative disease. While it affects motor function, the client's organs might be suitable for donation, provided they are otherwise stable and functioning well.

Recommended Action: •

C (A client who was in a motor vehicle accident).

Clients who experience trauma, especially if they can be declared brain dead, are often considered suitable organ donors, assuming their organs are functioning appropriately at the time of death. The circumstances of their death (e.g., brain death without irreversible organ damage) make them the most likely candidate for organ donation.

In evaluating arterial blood gas (ABG) results for a client who is hyperventilating, it's essential to understand the physiological response to hyperventilation.

Key Points:

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C: A client who was in a motor vehicle accident.

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Hyperventilation causes a decrease in carbon dioxide (CO2) levels (hypocapnia) due to increased exhalation.

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As CO2 decreases, pH typically rises (alkalosis) because CO2 is acidic; therefore, hyperventilation leads to respiratory alkalosis.

Analyzing the Options:

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pH: 7.31 (acidosis)

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PaCO2: 49 (elevated)

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HCO3: 22 (normal)

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Rationale: This indicates respiratory acidosis, which is not consistent with hyperventilation.

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pH: 7.48 (alkalosis)

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PaCO2: 31 (low)

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HCO3: 20 (slightly low)

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Rationale: This indicates respiratory alkalosis, which is expected in hyperventilation.

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pH: 7.47 (alkalosis)

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PaCO2: 52 (high)

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HCO3: 29 (normal)

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Rationale: This suggests respiratory acidosis, not consistent with hyperventilation.

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pH: 7.33 (acidosis)

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PaCO2: 29 (low)

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HCO3: 18 (low)

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Rationale: This indicates metabolic acidosis with respiratory compensation, which is also not typical for hyperventilation.

B:

C:

D:

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A:

Recommended Answer: •

B (pH: 7.48, PaCO2: 31, HCO3: 20).

In responding to the moral distress experienced by nurses in the intensive care unit, it’s important to take actions that validate their feelings and provide support. Here’s an evaluation of the potential responses: Appropriate Responses: 1. Schedule a debriefing session to provide closure and assess for follow-up. o

Rationale: This approach allows staff to express their feelings and experiences, providing an opportunity for emotional processing and closure. It’s crucial in addressing moral distress.

2. Set up meetings with the nurses to discuss the situation. o

Rationale: Open communication is vital in addressing moral distress.

Regular meetings allow nurses to voice concerns and feel heard, fostering a supportive environment.

3. Create a private space for staff to sit uninterrupted to relax.

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This option reflects the expected ABG results for a client who is hyperventilating, showing respiratory alkalosis due to decreased CO2 levels.

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Rationale: Providing a space for relaxation can help nurses decompress and reduce stress, which is beneficial for their mental well-being.

Inappropriate Responses: 1. Ignore the issue, as it will likely resolve in a short period of time. o

Rationale: Ignoring the issue can exacerbate the distress and lead to a toxic work environment. It’s crucial to address the feelings of moral distress directly.

o

Rationale: This response invalidates the nurses’ feelings and does not provide the support they need. Advising them to simply let it go can lead to further frustration and resentment.

Summary: The best responses involve facilitating discussions and providing space for staff to express their feelings, which are essential in addressing moral distress effectively.

Therefore, the appropriate actions are: Schedule a debriefing session, Set up meetings with nurses, and Create a private space for relaxation.

In assessing a client with decreased cardiac output, it's crucial to identify which findings indicate a need for immediate intervention. Here’s the evaluation: A: Confusion, urine output of 15 mL over the last two hours, and orthopnea.

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2. Speak with the nurses and advise them to let it go.

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Rationale: Confusion indicates potential cerebral hypoperfusion. The low urine output (15 mL) signifies possible acute kidney injury or significant fluid retention, which is critical in cardiac output management. Orthopnea suggests that the client is struggling with fluid overload or heart failure. This option indicates a need for immediate intervention.

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Rationale: A 2-pound weight gain may suggest fluid retention, but blood pressure and dyspnea is relatively mild. While this requires monitoring, it does not indicate immediate danger.

C: Blood pressure of 110/62 mmHg, atrial fibrillation with a heart rate of 74 beats per minute, and crackles in bilateral lungs.

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Rationale: Although the blood pressure is on the lower side and crackles indicate possible fluid overload in the lungs, the heart rate and level of concern are not as acute as in option A. This situation should be monitored but does not require immediate intervention.

D: SpO2 of 92% on 2 liters of oxygen, respirations of 20 breaths per minute, and 1+ edema of lower extremities.

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Rationale: An SpO2 of 92% is low but may not require immediate intervention at this quantity, especially given the supplemental oxygen. Respirations are within an acceptable range, and 1+ edema reflects mild fluid retention.

Recommended Answer: •

A (Confusion, urine output of 15 mL over the last two hours, and orthopnea).

This option signifies potential acute complications such as renal failure and cardiac overload, mandating urgent intervention.

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B: Weight gain of 2 pounds in three days, blood pressure of 130/80 mmHg, and mild dyspnea with exercise.

A: ST elevation on the EKG •

Rationale: ST segment elevation typically indicates ongoing myocardial ischemia or injury, which is common during an acute MI, but it may not directly correlate with developing heart failure three days later.

B: Rub heard on auscultation •

Rationale: A pericardial rub could indicate pericarditis, a complication of MI. While concerning, it may not be the most direct indication of heart failure.

C: Narrow pulse pressure •

Rationale: Narrowing of the pulse pressure (the difference between systolic and diastolic blood pressure) often indicates decreased cardiac output and may suggest impending heart failure. This finding is significant and directly supports concern for heart failure.

D: Decreased urine output •

Rationale: Decreased urine output is a classic sign of poor renal perfusion due to reduced cardiac output, and it can indicate heart failure. However, it’s often a secondary sign; thus, while indicative, it does not directly signal cardiac dysfunction as prominently as narrowing pulse pressure.

Recommended Answer: •

C (Narrow pulse pressure).

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In evaluating the assessment findings for a client admitted with acute myocardial infarction (AMI) who may be developing heart failure, let's analyze the options:

In assessing which client may require intubation and mechanical ventilation, let’s analyze each option carefully: A: A client who has a concussion and is mildly disoriented.

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Rationale: While a concussion can lead to altered mental status, the fact that they are only "mildly disoriented" does not necessarily indicate immediate respiratory failure or the need for intubation.

B: A client who has pneumonia and a productive cough.

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Rationale: Pneumonia can cause respiratory distress, but if the client is still maintaining adequate oxygenation without significant respiratory failure, they may not require intubation yet. Assessment of vital signs and oxygen levels would be needed.

C: A client who has angioedema related to an allergic reaction.

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Rationale: Angioedema can cause airway obstruction. If there is significant swelling obstructing the airway or signs of respiratory distress, this client may be at risk for requiring intubation.

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This finding best supports the nurse's concern for developing heart failure, as it reflects compromised cardiac output and is critical in the assessment of a post-MI patient.

D: A client who has emphysema and a slightly elevated PaCO2.

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Rationale: While elevated PaCO2 indicates possible respiratory failure, being "slightly elevated" and the presence of emphysema may not necessarily suggest immediate need for intubation depending on the overall clinical picture.

Recommended Answer: •

C (A client who has angioedema related to an allergic reaction).

In this scenario, the nurse is caring for a client with signs suggesting a possible acute coronary syndrome (chest pressure, dyspnea, and low SpO2). Here’s the evaluation of the options: A: Insert an intravenous (IV) catheter.

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Rationale: Inserting an IV is important for medication administration and fluid resuscitation. However, this does not address the immediate need for oxygen and symptom management.

B: Administer prescribed aspirin.

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This client is at the highest risk for airway obstruction due to swelling and may require immediate intervention, including intubation, to ensure airway patency.

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Rationale: Aspirin is critical in acute coronary syndrome to help inhibit platelet aggregation and prevent further clot formation. However, this should be done after ensuring that the client is stable enough for oral administration.

C: Obtain a blood sample for troponin.

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Rationale: A troponin test can help diagnose myocardial infarction, but it does not provide immediate relief for the client's current symptoms or improve oxygenation.

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Rationale: The client is experiencing dyspnea and has an SpO2 of 89%, indicating hypoxemia. Administering oxygen is a priority because it directly addresses the immediate respiratory distress and helps stabilize the client.

Recommended Answer: •

D (Initiate oxygen therapy).

This action should be taken first to improve the client’s oxygen saturation and address the immediate symptoms of dyspnea and hypoxemia before proceeding with other interventions.

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D: Initiate oxygen therapy.

Recommended Selection: Priority Actions to Take: 1. Provide education about cessation of drug use.

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Based on the information provided, the client ingested cocaine and is experiencing significant chest pain and respiratory symptoms. The priority actions and parameters to monitor should address the acute situation related to potential cocaine withdrawal or acute complications from cocaine use.

o

Rationale: Addressing substance abuse is critical for the client’s longterm health. Educating the client about the dangers of continued cocaine use is necessary for preventing future complications.

2. Collect blood for cardiac enzyme lab analysis. o

Rationale: Given the client’s chest pain and history of cocaine use, it's essential to evaluate for possible myocardial infarction or cardiac damage.

Cardiac enzymes will help in diagnosing any acute myocardial injury.

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Cocaine withdrawal. o

Rationale: The history of cocaine use, combined with chest pain, dyspnea, and other physical signs, suggests that the client may be experiencing complications related to cocaine use or withdrawal which can lead to cardiovascular issues.

Priority Parameters to Monitor: 1. Blood pressure. o

Rationale: Monitoring blood pressure is crucial in assessing the client’s cardiovascular status, especially since cocaine can cause fluctuations in blood pressure that might require immediate attention.

2. Respiratory rate. o

Rationale: The client is experiencing shortness of breath; therefore, monitoring respiratory rate is important for identifying any worsening respiratory distress or failure.

Summary: •

Actions: Provide education about cessation and collect cardiac enzyme labs.

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Condition: Cocaine withdrawal.

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Parameters: Monitor blood pressure and respiratory rate.

These priorities ensure the immediate physical needs of the client are addressed while also considering the long-term implications of substance use.

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Potential Condition:

Nursing Actions to Consider: A: Keep the client's hip and leg straight.

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Rationale: Yes, this action is essential to prevent strain on the puncture site and reduce the risk of bleeding or hematoma formation.

B: Assess capillary refill of the affected extremity.

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Rationale: Yes, this is important to evaluate perfusion to the affected leg and ensure there are no complications related to arterial blood flow following the procedure.

C: Encourage the client to ambulate.

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Rationale: No, immediately after a cardiac catheterization via the femoral artery, the client should not ambulate as this can increase the risk of bleeding or complications at the puncture site. Mobility should be restricted until approved by the healthcare provider.

D: Apply a heating pad to the puncture site.

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Following a cardiac catheterization via the femoral artery, it is crucial for the nursing care plan to focus on preventing complications and ensuring the patient's safety. Here’s an evaluation of each option provided:

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Rationale: No, applying heat can lead to vasodilation and may increase the risk of bleeding at the puncture site. Cold applications are typically more appropriate to manage any swelling.

E: Monitor the client's urine output.

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Rationale: Yes, monitoring urine output is important, especially post-cardiac procedures, as it helps assess kidney function and fluid status, which can be impacted by contrast use during the catheterization.

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Select A, B, and E.

Final Thoughts: These actions are crucial for ensuring patient safety and monitoring for potential complications following a cardiac catheterization through the femoral artery.

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Recommended Answers:

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Vital Signs & Key Findings: •

Temperature: 101.1°F (indicates fever)

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Heart Rate: 124 beats per minute (tachycardic)

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Blood Pressure: 178/96 mmHg (hypertensive)

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Respiratory Rate: 32 breaths per minute (tachypneic)

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Oxygen Saturation: 64% (hypoxemic)

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Cough with thick, greenish sputum

•

Labored breathing with use of accessory muscles

•

Diminished lung sounds, particularly in the right lower lobe

•

Capillary refill: 3 seconds

•

Lethargic but oriented to person and place

Prioritization of Findings: 1. A: Cough with green sputum o

Rationale: Indicates a potential infection (e.g., pneumonia) given the color of the sputum, which may contribute to the client's worsening respiratory status and hypoxia.

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Based on the clinical data and nursing notes provided for the client with respiratory distress, the following analysis can be made regarding which findings should be prioritized:

2. B: Lung sounds o

Rationale: Diminished lung sounds suggest poor air exchange, potentially related to consolidation or atelectasis. This is critical to assess the severity of respiratory distress.

3. D: Vital signs Rationale: Vital signs show significant tachycardia, hypertension, and severe hypoxia. These are urgent indicators of respiratory failure that require immediate intervention.

Less Critical Findings: •

C: Client’s weight o

•

While weight is important for overall assessment and medication dosing, it is less urgent in this acute situation.

E: Client orientation o

The client is oriented to person and place but lethargic, indicating a level of concern. However, the primary focus should be on the respiratory distress and vital signs.

Recommended Priorities: •

Select A (Cough with green sputum), B (Lung sounds), and D (Vital signs).

By prioritizing these findings, the nursing action can focus on immediate interventions to improve the client's respiratory status and address any potential infections while monitoring cardiovascular stability.

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o

RNstudentresources.com Given the information regarding the client's arterial blood gas (ABG) results, we can analyze the situation to determine the appropriate action.

ABG Results Overview: •

pH: 7.24 (Acidosis; normal is 7.35-7.45)

•

PaCO2: 69 mm Hg (Elevated; normal is 35-45 mm Hg)

•

HCO3: 30 mEq/L (Slightly elevated; normal is 22-26 mEq/L)

•

PaO2: 57 mm Hg (Hypoxemia; normal is 80-100 mm Hg)

Condition Assessment:

•

Severe Respiratory Acidosis: The low pH and high PaCO2 suggest that the client is retaining carbon dioxide, leading to the acidosis.

•

Severe Hypoxemia: The low PaO2 shows inadequate oxygenation.

Recommended Action: Given this critical state of respiratory distress, the nurse should anticipate that the respiratory therapist needs to: Increase the FiO2 % of the BiPAP settings •

Rationale: Due to the low PaO2 (57 mm Hg), increasing the FiO2 will help improve oxygenation. Since the patient is already on BiPAP, adjusting the oxygen concentration is essential to address the hypoxemia and support the gas exchange.

Conclusion: •

Recommended Choice: Increase the FiO2 % of the BiPAP settings.

This intervention directly addresses the client's hypoxemia, which is a critical priority given the current arterial blood gas results.

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The results indicate:

In this scenario, the nurse is caring for a critically ill client on a ventilator, and the family wishes to ensure that the client will not be resuscitated if conditions worsen. The best course of action needs to be identified among the provided options.

Analysis of Options: A: Notify the healthcare provider that the family would like to request a donot-resuscitate (DNR) status for the client.

Rationale: This option allows the healthcare team to document the family's wishes and initiate the process to establish a DNR order formally. This is an appropriate and professional action.

B: Explain to the family that it is up to the healthcare provider and team whether to perform or withhold resuscitation efforts.

•

Rationale: While technically true, this response may be dismissive of the family's concerns and does not provide the guidance or support they need regarding their wishes.

C: Follow the family's wishes and withhold resuscitation efforts if the client's condition worsens.

•

Rationale: Not appropriate as the family’s wishes need to be formally documented through a DNR order. Without an official DNR, the medical team would still need to follow standard resuscitation protocols.

D: Wait until the client is able to make their wishes known before making any decisions and support the family.

•

Rationale: This does not align with patient-centered care, especially since the client is currently incapacitated and cannot express their wishes. It may cause unnecessary distress to the family.

Recommended Answer: •

A: Notify the healthcare provider that the family would like to request a do-not-resuscitate (DNR) status for the client.

This action ensures that the family’s wishes are communicated and considered in the decision-making process regarding the client's care and aligns with ethical standards in healthcare.

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•

RNstudentresources.com Assessment Findings Analysis 1. Assessment Findings at 0400: •

Reports no shortness of breath: o

•

Improving: Indicates the patient is stable regarding respiratory status.

Blood pressure 145/82 mmHg:

o

Bilateral crackles noted in the bases of the lungs: o

•

Heart rate 94 beats per minute: o

•

Improving: This heart rate is within a somewhat normal range, depending on the patient’s baseline and context.

Oxygen saturation of 94% on 4 L O2 via nasal cannula: o

•

Declining: This finding suggests possible fluid accumulation or pneumonia, indicating respiratory compromise.

Improving: While slightly low, this level of oxygen saturation is acceptable with supplemental oxygen. It indicates the patient is responding to treatment.

2+ pitting edema legs and sacrum: o

Declining: Edema can indicate fluid overload or heart failure, which is a concerning sign.

Summary of Findings: •

Improving: Reports no shortness of breath, blood pressure 145/82 mmHg, heart rate 94 bpm, oxygen saturation of 94% on 4 L O2.

•

Declining: Bilateral crackles, 2+ pitting edema.

2. Ventricular Pacer Spike Identification: To identify the ventricular pacemaker spike on the provided ECG strip, look for a narrow vertical line before each QRS complex that indicates the pacing of the ventricle.

Identifying the Spike: •

The ventricular pacer spike is typically represented as a vertical line immediately preceding the QRS complex.

•

Select the point where the pacemaker spike corresponds to a QRS complex on the ECG.

Recommended Strategy:

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•

Improving: This BP is relatively normal range for a patient, suggesting stabilization.

•

Note: Without visualizing the ECG strip directly, ensure to examine positions A, B, C, and D carefully for the narrow vertical lines immediately preceding the ventricles' depolarization (the QRS complex).

•

For the assessment findings at 0400, mark improving or declining accordingly.

•

For the ECG reading, accurately identify the pacer spike by selecting the appropriate location where the spike appears before the QRS complex.

If you have specific questions about any of the options or need more detailed analysis, feel free to ask!

When determining which clients require an oropharyngeal airway, we must consider each case's specific respiratory needs and risks. Here's the rationale for each option: Assessment of Each Client: A: A client with a basilar skull fracture who is postictal after a seizure.

•

Rationale: This client can have compromised airway protection due to altered consciousness. The risk of airway obstruction is high, making them a candidate for an oropharyngeal airway.

B: A client who is recovering from anesthesia and has nasal polyps.

•

Rationale: While recovering from anesthesia can involve airway issues, the presence of nasal polyps may make nasopharyngeal airways more suitable. An

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Conclusion:

oropharyngeal airway might not be immediately indicated here due to potential obstruction or risk of trauma.

C: A client who had an acute stroke and has limited mouth-opening ability.

•

Rationale: Limited mouth opening may complicate the insertion of an oropharyngeal airway. This client might require alternative airway management options.

•

Rationale: This client is at risk for airway compromise. An oropharyngeal airway can be beneficial in maintaining the airway during suctioning.

E: A client who is intubated and chewing on the endotracheal tube.

•

Rationale: This situation presents a severe risk for airway obstruction and dislodgement of the endotracheal tube. An oropharyngeal airway can help maintain patency of the airway.

Recommendations: •

Select A, D, and E.

Conclusion: •

A (basilar skull fracture) is at high risk for airway obstruction.

•

D (semi-conscious) needs airway maintenance during suctioning.

•

E (intubated) needs protection against occlusion and tube dislodgment.

Clients B and C may not be suitable candidates for an oropharyngeal airway based on their specific conditions.

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D: A client who is semi-conscious and requires nasotracheal suctioning.

Recommended Action: The priority action for the nurse in this scenario should be to: Gather endotracheal intubation supplies.

•

Rationale: Given that the client has become unresponsive and the carotid pulse is not palpable, this indicates a potential cardiac arrest situation. Immediate action must be taken, which includes preparing for airway management if needed. Endotracheal intubation supplies will be necessary for advanced airway management, especially if resuscitation efforts (like CPR) are unsuccessful or if the patient cannot maintain their own airway.

Other Considerations: •

Start CPR: While gathering supplies, the nurse should simultaneously initiate or assist with CPR if it hasn’t already been started, as this is critical in a cardiac arrest scenario.

•

Defibrillation: If the client is in a shockable rhythm (such as ventricular fibrillation), defibrillation should occur as soon as possible.

Conclusion:

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In the case presented, the client is experiencing symptoms consistent with a cardiac event, and the cardiac monitor displays a rhythm that likely indicates a severe arrhythmia such as ventricular fibrillation or pulseless ventricular tachycardia (noted by the chaotic pattern with no discernable QRS complexes).

When educating a client who is being discharged with a new nitroglycerin prescription following a myocardial infarction, the nurse should provide information on safely resuming sexual activity. Below is the evaluation of each option: Options Analysis: A: Erectile dysfunction medications should not be taken when taking nitroglycerin.

•

Rationale: True. This is important information. The combination can lead to severe hypotension, as both nitroglycerin and erectile dysfunction medications (like sildenafil) cause vasodilation.

B: Avoid intensely hot or extremely cold showers after intercourse.

•

Rationale: While extreme temperatures can affect blood pressure, this statement is less commonly emphasized. It's not a primary focus of teaching.

C: Increase food and caloric intake prior to engaging in sexual activity.

•

Rationale: This statement is generally unnecessary for most clients and isn't specifically linked to the safe resumption of sexual activity post-myocardial infarction.

D: It is generally safe to resume sexual activity three to five days after discharge.

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The immediate next step should involve ensuring the airway is secured, prioritizing gathering endotracheal intubation supplies while also being prepared to perform CPR and other resuscitation measures as needed.

•

Rationale: True. Many healthcare providers recommend waiting a short duration post-discharge before resuming sexual activity, but this can vary based on the specific client's condition.

E: Sex is a physical activity that should be resumed slowly after having a heart attack.

•

Rationale: True. It is typically advised to approach sexual activity with caution and to listen to the body, gradually resuming normal activity as tolerated.

•

Select A, D, and E.

Conclusion: These options provide important safety information regarding the use of nitroglycerin, timing for resuming sexual activity, and the need for a gradual approach after a cardiac event. Options B and C are less critical in the context of this teaching.

In the scenario provided, the nurse is caring for a client immediately after a permanent pacemaker insertion, and the cardiac monitor shows pacemaker spikes without associated QRS complexes. This situation indicates that the pacemaker is firing, but the heart is not responding appropriately.

Analysis of Each Action: A: Prepare the client for defibrillation.

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Recommended Answers:

•

Rationale: This is inappropriate in this context. Defibrillation is used for shockable rhythms (like ventricular fibrillation or pulseless ventricular tachycardia), not for a situation where the pacemaker spikes indicate that the device is functioning without capturing the heart.

B: Feel for the presence of a palpable pulse.

•

Rationale: This is a critical action. Assessing for a pulse will provide information about the heart's effectiveness in responding to the pacemaker’s signals. If there’s no pulse, immediate interventions are necessary.

•

Rationale: This action is not indicated. Positioning the client does not address the primary issue of inadequate pacemaker function and may not resolve the situation.

D: Contact the rapid response team.

•

Rationale: This is also a prudent action, especially if the nurse suspects that the patient is in distress or not responding appropriately. However, assessing the pulse first will help determine the urgency of the situation before activating the rapid response team.

Recommended Action: •

Select B: Feel for the presence of a palpable pulse.

Conclusion: By checking for a pulse first, the nurse can gauge whether the pacemaker is providing effective support to the client's heart. If there is no pulse, then the next steps would include contacting the rapid response team and initiating CPR. This approach prioritizes immediate assessment of the client's hemodynamic status.

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C: Have the client move onto their right side.

Let's analyze each assessment finding at 2000 to determine if it is improving or declining: 1. Blood Pressure: 142/80 mmHg •

Rationale: This blood pressure is within acceptable range (normal is generally 90/60 mmHg to 120/80 mmHg). If this is an improvement from a previous reading or stable, it can be marked as Improving. However, if this is high compared to recent readings, it may warrant further concern.

2. Skin is cool and moist •

Rationale: Cool and moist skin can indicate poor perfusion or potential shock.

If this has not improved from previous assessments, it would be marked as Declining. If it was previously warmer and drier, then this is a concern.

3. Heart Rate: 132 beats per minute •

Rationale: A heart rate of 132 is elevated (tachycardia). If this has increased from previous assessments or is consistent with worsening conditions, it should be marked as Declining. If it has decreased from a higher rate, it would trend towards Improving.

4. Chest Pain: 6/10 on a 1-10 pain scale •

Rationale: A pain level of 6 indicates significant discomfort. If the pain level has increased from a lower level, it should be marked as Declining. If it has decreased, it can be considered Improving.

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Assessment Findings Analysis

5. Pulse Oximetry: 92% on 4L nasal cannula •

Rationale: A saturation of 92% is at the lower end of normal (considered acceptable, but ideally above 92-94%, especially for those with respiratory issues). If this is similar to prior readings, it may not change; however, if it has dropped from a higher number, it would be Declining.

•

Rationale: A respiratory rate of 24 is elevated (tachypnea), which can indicate distress or a compensatory response to distress. If this increased from a stable lower rate, it should be marked as Declining. If it was already elevated or improving, its status may remain neutral.

Final Assessment Marking: •

Blood Pressure: Improving (if stable; if rising, then Declining)

•

Skin: Declining (cool and moist indicates potential issues)

•

Heart Rate: Declining (tachycardia, particularly if increased)

•

Chest Pain: Declining (6/10 indicates significant pain)

•

Pulse Oximetry: Declining (if consistently below previous readings)

•

Respirations: Declining (if increased from a more stable rate)

Conclusion: This assessment shows multiple findings indicating a potential decline in the client's condition. The nurse should closely monitor these changes and take appropriate actions based on the overall assessment.

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6. Respirations: 24 breaths per minute

Options Analysis: A: Reposition the client every two hours.

•

Rationale: Repositioning is important in preventing pressure injuries and promoting better lung expansion. However, every two hours may not be frequent enough for a critically ill client, especially one who is intubated and at risk for complications.

B: Schedule suctioning to occur every hour.

•

Rationale: Routine suctioning every hour may not be necessary unless there is an indication of secretions that need to be cleared. Suctioning too frequently can irritate the airway and lead to complications. Suctioning should be based on clinical assessment rather than a scheduled routine.

C: Discourage family visits to the client.

•

Rationale: Family involvement is generally encouraged for critically ill patients.

While there may be instances when visits should be limited, discouraging family visits could be detrimental to the client's emotional well-being and support system.

D: Place the client in a supine position.

•

Rationale: While supine positioning is common, it may not be the best position for a client with respiratory failure. Elevating the head of the bed can help

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In caring for a client in the ICU with acute respiratory failure who is intubated, the following analysis helps determine the best action to incorporate into the care plan.

improve oxygenation and facilitate better lung expansion for an intubated patient.

Recommended Action: •

None of the options appears optimal. However, among them, A (Reposition the client every two hours) is the best action given that pressure injury prevention is important. It would be beneficial to position the client properly (like semi-Fowler's) more frequently, but this option is the best available.

In the context of care for an intubated client in respiratory failure, positioning strategies (like elevating the head of the bed) and family involvement are crucial. Therefore, while A is the best of the options presented, adaptation and more frequent assessments are necessary for optimal client care.

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Conclusion:

RNstudentresources.com Based on the information provided from the electronic health record regarding the client with significant respiratory distress (as indicated by high PaCO2, low PaO2, and shallow respirations), we need to determine the most appropriate initial action.

Laboratory Results Summary: 1. PaCO2: 68 mm Hg (indicating hypercapnia) 2. PaO2: 56 mm Hg (indicating severe hypoxia) 3. HCO3: 26 mEq/L (suggesting normal metabolic compensation)

Assessment of Each Action: A: Gather supplies for central line placement.

•

Rationale: While a central line may be essential for medication administration or fluid resuscitation, this action does not directly address the immediate respiratory crisis.

•

Rationale: Given the severe hypoxia (PaO2 of 56) and hypercapnia (PaCO2 of 68), the client may quickly deteriorate. Preparing for intubation is critical in ensuring the airway is secured and breathing is supported. This action directly addresses the life-threatening respiratory failure.

C: Administer a 0.9% sodium chloride IV bolus infusion.

•

Rationale: While intravenous fluids can be important, they do not directly address severe respiratory failure. Administering fluids is secondary compared to securing the airway and ensuring adequate ventilation.

D: Obtain a prescription for continuous renal replacement.

•

Rationale: This action is unrelated to the immediate respiratory distress and does not take priority in the context of this severe respiratory crisis.

Recommended Action: •

Select B: Prepare for rapid sequence intubation.

Conclusion: Securing the airway through intubation should be the nurse's highest priority given the acute respiratory failure indicated by the lab results and clinical signs. This is crucial for ensuring adequate ventilation and oxygenation before addressing other concerns.

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B: Prepare for rapid sequence intubation.

Analysis of Each Action: A: Reassure the client that these symptoms are common and will subside.

•

Rationale: While it is true that some symptoms post-extubation can be common, it’s essential to be cautious with reassurance if there are signs of airway obstruction or respiratory distress. This option could downplay a potentially serious issue.

B: Instruct the client to limit speaking to decrease vocal cord irritation.

•

Rationale: Limiting speaking can help reduce irritation; however, this does not address the immediate concern of airway patency and the noise the client is making.

C: Encourage the client to cough and deep breathe every two hours.

•

Rationale: Coughing and deep breathing are generally good practices to clear secretions and enhance lung expansion, but this does not prioritize the immediate airway concerns related to the high-pitched noise.

D: Monitor airway and inform the client that reintubation may be necessary.

•

Rationale: This option prioritizes safety by acknowledging the potential for airway obstruction. Monitoring the airway closely is crucial in this situation due

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In the scenario presented, the adult client has just been extubated and is exhibiting symptoms of coughing and producing a high-pitched noise while inhaling. This noise could indicate potential airway complications, such as stridor, which may signal that the airway is compromised.

to the signs of stridor. It prepares both the nurse and the client for the possibility of requiring reintubation if the situation worsens.

Recommended Action: •

Select D: Monitor airway and inform the client that reintubation may be necessary.

In this scenario, the priority nursing action should focus on ensuring the airway is patent and recognizing that there may be a need for reintubation. This approach addresses the immediate safety concern for the client following extubation.

In the given scenario, the client is showing signs of confusion, agitation, and hallucinations after surgery. Let’s analyze the options provided and determine the most likely complication.

Options Analysis: A: Postoperative delirium •

Rationale: Delirium is common in the postoperative period, particularly in older adults. Symptoms include confusion, agitation, and hallucinations, which match the client’s presentation. This is a likely diagnosis given the timing (3 days post-surgery) and the symptoms.

B: Postoperative infection

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Conclusion:

•

Rationale: While infection can lead to altered mental status, it typically presents with other signs such as fever, increased heart rate, or localized pain.

Confusion and hallucinations alone are not definitive indicators of infection.

C: Senile dementia •

Rationale: Although dementia can cause confusion, it is typically a chronic condition that develops over time. It is unlikely to present acutely in a client who has previously been stable and is now showing new symptoms post-surgery.

•

Rationale: Polypharmacy (the use of multiple medications) can lead to confusion and agitation, but it’s less likely to be the primary cause compared to postoperative delirium in an acute setting. Moreover, the scenario does not specifically indicate the use of multiple medications.

Recommended Action: •

Select A: Postoperative delirium.

Conclusion: The symptoms of confusion, agitation, and hallucinations occurring three days after surgery strongly suggest postoperative delirium. This condition can lead to significant complications if not recognized and managed promptly, making it the most likely complication in this scenario.

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D: Polypharmacy

Based on the rhythm shown on the cardiac monitor, let's analyze the potential medication to anticipate for the client.

Rhythm Analysis The rhythm appears to show: •

A regular pattern with narrow QRS complexes and normal P waves.

•

This pattern may indicate supraventricular tachycardia (SVT).

A: Diltiazem •

Rationale: Diltiazem is a calcium channel blocker that is effective in treating SVT. It works by slowing the conduction through the AV node and reducing heart rate, making it a commonly used medication for cases of rapid atrial rhythms such as atrial fibrillation or SVT.

B: Epinephrine •

Rationale: Epinephrine is typically used in cases of cardiac arrest or severe allergic reactions. It is not the first-line treatment for SVT and could potentially complicate the situation by increasing heart rate even further.

Recommended Medication: •

Select A: Diltiazem.

Conclusion: Given the rhythm observed on the monitor, the most appropriate medication the nurse would anticipate is Diltiazem, as it effectively manages SVT and helps stabilize the client’s heart rate.

You ans and rationale

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Medication Options:

Options Analysis: A: Suction equipment •

Rationale: Suctioning is essential for intubated patients to maintain airway patency and clear secretions. This is critical in preventing complications like pneumonia, so having suction equipment readily available is vital.

B: Bag-valve-mask resuscitator •

Rationale: A bag-valve-mask (BVM) is crucial for emergency situations where the ventilator may fail or if the patient becomes apneic. It is essential to have this equipment for immediate respiratory support.

C: Chlorhexidine oral care supplies •

Rationale: Oral care is important for intubated patients to prevent ventilatorassociated pneumonia and maintain oral hygiene. Having chlorhexidine supplies for oral care is recommended as part of the daily care routine.

D: Communication board

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In caring for a client who is intubated and mechanically ventilated, several supplies are crucial for effective management and care. Let’s analyze each option regarding its relevance.

•

Rationale: This can be helpful for patients who are conscious and intubated, but it is not essential for immediate care if the patient is sedated or unable to communicate.

E: Venturi mask •

Rationale: A Venturi mask is typically used for clients who are not intubated and require precise oxygen delivery. Since the client is intubated, this item is not necessary.

•

A: Suction equipment

•

B: Bag-valve-mask resuscitator

•

C: Chlorhexidine oral care supplies

Conclusion: For a client who is intubated and mechanically ventilated, it is essential to have suction equipment, a bag-valve-mask resuscitator, and chlorhexidine oral care supplies readily available to ensure the patient’s airway is managed effectively and to prevent complications. The communication board is helpful but not critical, and a Venturi mask is irrelevant in this context.

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Recommended Selections:

Assessment Findings Evaluation: 1. Blood Pressure: 142/80 mmHg o

Rationale: This blood pressure reading is within an acceptable range (though somewhat elevated), indicating stable hemodynamics. If this is an improvement compared to previous readings or stable, this can be marked as Improving.

2. Skin: Cool and moist o

Rationale: Cool and moist skin can be a sign of inadequate perfusion, which is concerning. If this has not improved from prior assessments, it would be marked as Declining.

3. Heart Rate: 132 beats per minute o

Rationale: A heart rate of 132 is indicative of tachycardia. If this has changed from previous assessments and is higher than before, it would be considered Declining.

4. Chest Pain: 6/10 on a 1-10 pain scale

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Based on the provided nursing notes and assessment findings at 2000 for the client with respiratory distress, we need to evaluate each parameter to determine whether the client's condition is improving or declining.

o

Rationale: A chest pain level of 6 suggests significant discomfort or distress. If this level has increased from previous assessments or has not changed, it would be marked as Declining.

5. Pulse Oximetry: 92% on 4L nasal cannula o

Rationale: A pulse oximetry reading of 92% is low, particularly for someone on supplemental oxygen. If this has dropped from a higher reading, it should be marked as Declining. If stable but on the lower end, it may also trend towards Declining.

o

Rationale: A respiratory rate of 24 indicates tachypnea. If this has increased from a stable or lower rate, it is likely Declining.

Summary of Findings: •

Blood Pressure: Improving (if stable or better than previous)

•

Skin: Declining (cool and moist indicates potential issues)

•

Heart Rate: Declining (tachycardia)

•

Chest Pain: Declining (6/10 indicates significant pain)

•

Pulse Oximetry: Declining (92% is low for supplemental oxygen)

•

Respirations: Declining (if increased from previous rates)

Recommendations: •

Overall: Most findings indicate the client's condition is Declining except possibly for the blood pressure, which may be stable or slightly elevated. The healthcare team should monitor closely and consider interventions for the declining parameters.

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6. Respirations: 24 breaths per minute

Options Analysis: A: "Organ donation can help save lives, and that is something to be thankful about."

•

Rationale: While this statement is indeed true, it may come across as a bit insensitive to the family's grief. It lacks emotional support and does not directly address their feelings or concerns.

B: "Maybe you should speak with your religious leader to find out what they think about a donation."

•

Rationale: This suggests deferring the decision to a religious leader, which could be helpful but may not provide immediate support. It indirectly avoids addressing the family's emotional state.

C: "I think you will feel better about the situation if you donate your spouse’s organs."

•

Rationale: This statement places undue pressure on the family by implying that donation is a way to feel better. It may be seen as minimizing their grief and personal decision-making process.

D: "Thinking about what your spouse would have wanted in this situation may be helpful."

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In addressing the family's questions about organ donation for a client who has been declared brain-dead, it's crucial to provide compassionate and supportive responses.

Let's evaluate each option.

•

Rationale: This option encourages reflection and allows the family to consider their loved one’s wishes or values. It acknowledges their emotional state and promotes a thoughtful discussion about organ donation in a way that respects their feelings.

Recommended Response: •

Select D: "Thinking about what your spouse would have wanted in this situation may be helpful."

Option D is the best choice as it provides a compassionate and respectful approach, encouraging the family to reflect on their loved one’s values and preferences while navigating a difficult decision. This response fosters a supportive environment for the family during a challenging time.

In the scenario where a client is diagnosed with ST-segment elevation myocardial infarction (STEMI) and is preparing for a percutaneous coronary intervention (PCI), it's important to determine the best action for the nurse to take next.

Options Analysis: A: Ask the client about previous reactions to contrast dye •

Rationale: This is crucial because contrast agents may be used during PCI, and knowing prior reactions can prevent potential complications such as allergic reactions or contrast-induced nephropathy. This step is significant for patient safety.

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Conclusion:

B: Place the client on oxygen using a non-rebreather mask •

Rationale: Administering oxygen is important for clients with STEMI to improve oxygen delivery to the myocardium. However, this may be prioritized after ensuring baseline assessments like any allergy history.

C: Prepare to administer alteplase at the bedside Rationale: Alteplase is a thrombolytic agent indicated for STEMI treatment, but it’s typically given before PCI and not necessarily in the setting where PCI is planned. This action might not be the immediate next step without reviewing the overall treatment plan and contraindications.

D: Explain the procedure to the client •

Rationale: Explanation of the procedure is important for patient understanding and consent, but this should typically occur after addressing any critical safety measures, such as confirming allergies.

Recommended Action: •

Select A: Ask the client about previous reactions to contrast dye.

Conclusion: The best action for the nurse to take next is to inquire about the client’s history of reactions to contrast dye. This step is critical for ensuring the client's safety during the PCI procedure, allowing for the best care while minimizing risks. While providing oxygen and explaining the procedure are also important, confirming allergy history takes precedence in this situation.

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•

Options Analysis: A: Ensure at least three colleagues are available to assist with positioning.

•

Rationale: Prone positioning can be physically demanding and requires the safe handling of the client to prevent injury. Ensuring sufficient assistance is critical for the safety and effectiveness of the procedure. This is the best initial action to take.

B: Initiate the client's gastric tube feeding immediately before repositioning.

•

Rationale: Feeding should typically be paused before repositioning, especially in clients who are at risk for aspiration. This option could lead to complications and is not advisable.

C: Contact the provider for extubation before prone positioning.

•

Rationale: Extubation may not be appropriate at this stage, especially if the client requires mechanical ventilation due to ARDS. Therefore, this action does not align with best practices for managing a client in respiratory distress.

D: Keep the client in the prone position for at least 20 hours daily.

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When considering the implementation of prone positioning for a client with adult respiratory distress syndrome (ARDS), it's essential to prioritize safety and proper procedure.

•

Rationale: While maintaining prone positioning for a significant duration may be a goal, it is not an immediate action to take prior to the positioning itself. It’s more of an ongoing care plan rather than a preparatory step.

Recommended Action: •

Select A: Ensure at least three colleagues are available to assist with positioning.

The most appropriate action is to ensure adequate assistance for safe and effective prone positioning. This reduces the risk of injury to both the client and the staff during the procedure. Other options either present risks or do not address the immediate need for safe positioning.

Given the scenario where a client on mechanical ventilation has an oxygen saturation of 85% and clear lung sounds, let’s evaluate the options provided to identify the best action to improve the client’s oxygenation.

Options Analysis: A: Suctioning the client's endotracheal tube •

Rationale: Suctioning may be necessary if there are secretions obstructing the airway, but since lung sounds are reported as clear bilaterally, it suggests there are no significant secretions present that would warrant immediate suctioning.

Thus, this may not be the most urgent intervention.

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Conclusion:

B: Increasing the FiO2 setting on the ventilator •

Rationale: Increasing the FiO2 can directly improve oxygen saturation by providing higher concentrations of oxygen. This is a straightforward and effective way to address low oxygen saturation, especially in a mechanically ventilated patient whose baseline settings might require adjustment.

C: Administering a bronchodilator medication Rationale: A bronchodilator may be appropriate if bronchospasm were present, but clear lung sounds indicate that bronchospasm is not the issue at hand. This would not be the first-line intervention given the current assessment findings.

D: Placing the client in Trendelenburg's position •

Rationale: Trendelenburg's position is typically used to enhance venous return and may not be effective for improving oxygenation in cases of hypoxemia. This position could potentially worsen respiratory status by increasing abdominal pressure on the diaphragm.

Recommended Action: •

Select B: Increasing the FiO2 setting on the ventilator.

Conclusion: The best action to improve the client’s oxygenation in this scenario is to increase the FiO2 setting on the ventilator. This intervention directly addresses the low oxygen saturation by providing a higher concentration of oxygen, making it the most appropriate and effective choice given the context.

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