The nurse caring for a patient with an endotracheal tube un derstands that endotracheal suctioning is needed to facilitate removal of secretions. What additional information is the nurse aware of concerning this intervention?

Correct Answer: C

Rationale: Rationale for Correct Answer C: Endotracheal suctioning should be done as indicated by patient assessment because not all patients require routine suctioning. Performing unnecessary suctioning can lead to potential complications such as mucosal damage and increased risk of infection. Therefore, the nurse must assess the patient's respiratory status, auscultate lung sounds, monitor oxygen saturation levels, and observe for signs of increased secretions before deciding to perform suctioning. Summary of Incorrect Choices: A: Endotracheal suctioning does not directly impact intracranial pressure. It is primarily focused on maintaining airway patency and removing respiratory secretions. B: While endotracheal suctioning may temporarily suppress the cough reflex during the procedure, its primary purpose is to clear airway secretions to prevent complications such as atelectasis and respiratory distress. D: Saline instillation before suctioning is not recommended as it can lead to negative outcomes such as dehydration, mucosal damage, and increased risk of infection

Correct Answer: E

Rationale: The correct answer is not provided, but based on the events described, the official time of death recorded in the medical record should be 1810 (Choice D). At this time, the cardiac monitor shows flatline, indicating the cessation of cardiac activity, which is the universally accepted point of declaring death. Choice A (1300) is incorrect because that is when diagnostic tests for brain death were completed, but the patient was not officially declared dead at that time. Choice B (1330) is incorrect as this is when the primary care provider reviewed the test results and documented brain death in the progress note, but the patient was not officially declared dead at this time either. Choice C (1400) is incorrect as there is no significant event occurring at this time that signifies the patient's death. Therefore, the most appropriate and official time of death recorded in the medical record would be 1810 when the cardiac monitor shows flatline.

Correct Answer: C

Rationale: The correct answer is C: Stop and ventilate the patient with 100% oxygen. This is the priority action because PVCs can lead to life-threatening arrhythmias and inadequate oxygenation. By stopping suctioning and providing 100% oxygen, the nurse ensures proper oxygenation and ventilation, which takes precedence over addressing the dysrhythmia itself. Decreasing suction pressure (choice A) may not address the underlying issue and could potentially harm the patient. Documenting the dysrhythmia (choice B) is important but not as urgent as ensuring adequate oxygenation. Giving antidysrhythmic medications (choice D) should be done under the direction of a healthcare provider and is not the first-line intervention in this situation.

Correct Answer: D

Rationale: The correct answer is D: Respiratory alkalosis. Hyperventilation in severe asthma exacerbation leads to excessive removal of CO2, causing a decrease in carbonic acid levels, resulting in respiratory alkalosis. Metabolic acidosis (A) is not typically associated with hyperventilation. Metabolic alkalosis (B) is caused by excessive loss of acid or gain of bicarbonate, not by hyperventilation. Respiratory acidosis (C) is characterized by an increase in CO2 levels due to inadequate ventilation, which is the opposite of what occurs in severe asthma exacerbation.

Correct Answer: C

Rationale: Rationale: The correct answer is C because lack of knowledge about literature searches hinders the ability to find and utilize evidence-based practice guidelines. Nurses need to be skilled in conducting literature searches to access relevant research. Choices A, B, and D are incorrect as they do not directly impede the implementation of evidence-based practice in the critical care unit.

Correct Answer: C

Rationale: Correct Answer: C - Regular insulin Rationale: 1. Insulin promotes cellular uptake of potassium. 2. When insulin is administered, it moves potassium from extracellular to intracellular space. 3. This decreases plasma potassium levels safely. 4. Other options do not directly lower potassium levels in the same manner. Summary of Other Choices: A: Sodium polystyrene sulfonate - exchanges sodium for potassium in the intestines, not reducing total body potassium. B: Sodium polystyrene sulfonate with sorbitol - similar to A, does not reduce total body potassium. D: Calcium gluconate - does not directly lower potassium levels, used for treating hyperkalemia-induced cardiac toxicity.

Correct Answer: D

Rationale: The correct answer is D, the 70-year-old mother with blood type A positive. This choice is the best candidate for evaluation due to her blood type matching the patient's (A positive) for kidney transplantation. Age and medical history are also crucial factors in determining suitability. The 65-year-old brother (choice A) has hypertension, a significant risk factor. The 35-year-old female (choice B) with food allergies may have potential complications. The 14-year-old son (choice C) is underage and might not be a suitable donor due to age and the potential impact on his growth and development. In summary, choice D aligns with the matching blood type and age, making the mother the most suitable candidate for evaluation.

Correct Answer: B

Rationale: The correct answer is B because asking if the pain is sharp, dull, or crushing helps assess the quality of pain, providing specific information on the type of sensation felt. This is crucial for understanding the underlying cause and guiding appropriate treatment. A: Asking about pain being constant or intermittent addresses duration, not quality. C: Inquiring about what makes pain better or worse focuses on triggers, not quality. D: Asking when the pain started addresses onset time, not quality.

Correct Answer: B

Rationale: The correct answer is B because hospice care indeed focuses on providing support and comfort for patients at the end of life. This is achieved through pain management, emotional support, and enhancing quality of life. Choice A is incorrect because hospice care does not aim to cure serious illnesses but rather to provide comfort and care. Choice C is incorrect as hospice care is not limited to patients with cancer but is available to individuals with various terminal illnesses. Choice D is incorrect as hospice care does not focus on extending life expectancy but rather on improving the quality of life during the end-of-life period.