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

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.

Correct Answer: A

Rationale: The correct answer is A because in this situation, the patient is no longer able to make decisions for themselves due to being heavily sedated. The healthcare surrogate or proxy steps in to make decisions on behalf of the patient to ensure their comfort and well-being. Choice B is incorrect because the patient is competent and able to make their own decisions, so there is no need for a surrogate to take over decision-making. Choice C is incorrect because the patient is competent and has the right to make decisions about their own treatment, even if they go against medical recommendations. Choice D is incorrect because the patient is competent and receiving appropriate treatment for their pain and anxiety, so there is no need for a surrogate to intervene in this scenario.

Correct Answer: D

Rationale: The correct answer is D: Ask the family to complete the Critical Care Family Needs Inventory. This tool helps assess the family's needs and concerns, enabling the nurse to tailor care accordingly. By understanding the family's specific needs, the nurse can provide appropriate support and information, fostering better involvement and understanding. A: Asking one family member to assist with the patient's bath may not address the overall family's needs or involvement in care. B: Encouraging family members to stay longer does not necessarily address their specific needs or facilitate effective communication. C: Focusing solely on the legal next of kin may exclude important family members who also need support and involvement in the patient's care.

Correct Answer: D

Rationale: The correct answer is D: Work of breathing. Work of breathing refers to the amount of effort required to maintain a specific level of ventilation. This includes the energy needed for inhalation and exhalation. Compliance (A) refers to the ease with which the lungs expand, resistance (B) is the opposition to airflow in the airways, and tidal volume (C) is the amount of air moved in and out of the lungs during normal breathing. Work of breathing encompasses the overall energy expenditure involved in the breathing process, making it the most appropriate term in this context.

Correct Answer: D

Rationale: Pulse oximetry measures oxygen saturation in the blood by analyzing the absorption of light by hemoglobin. Oxygen saturation indicates the percentage of hemoglobin molecules carrying oxygen. This is essential for assessing respiratory function and oxygen delivery to tissues. Arterial blood gases (Choice A) directly measure oxygen and carbon dioxide levels in the blood, not specifically oxygen saturation. Hemoglobin values (Choice B) provide information about the amount of hemoglobin present but not its oxygen-carrying capacity. Oxygen consumption (Choice C) is a measure of how much oxygen is used by tissues, not what pulse oximetry directly measures.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates effective handoff communication by involving key stakeholders (nephrology consultant physician), requesting specific patient updates, and collaborating on patient care tasks (placing a central line). This scenario promotes continuity of care and ensures important information is shared. Explanation for why other choices are incorrect: B: High noise level disrupts communication and can lead to errors or omissions in handoff information. C: While using a standardized checklist can be beneficial, it alone does not guarantee effective communication if not utilized properly or if key information is missed. D: Conducting reports at the patient's bedside is beneficial for patient involvement but may not address the need for involving relevant healthcare providers like the consultant physician in the handoff process.

Correct Answer: B

Rationale: The correct answer is B: Hypoxemia and compensated respiratory acidosis. The patient's pH is within normal range (7.35), indicating compensation. The elevated PaCO2 (55 mm Hg) indicates respiratory acidosis due to inadequate ventilation, likely from COPD. The low PaO2 (65 mm Hg) indicates hypoxemia, common in pneumonia. The normal bicarbonate level (30 mEq/L) suggests metabolic compensation for respiratory acidosis. Choice A is incorrect as there is no metabolic alkalosis present. Choice C is incorrect as the patient has hypoxemia. Choice D is incorrect as the patient is showing compensated respiratory acidosis, not uncompensated.

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.

Correct Answer: B

Rationale: The correct answer is B because it shows understanding that the PAC helps in managing fluid therapy effectively. The PAC measures pressures in the heart and lungs, guiding fluid management. Choice A is incorrect as the PAC is not primarily for IV fluid administration. Choice C shows understanding of the catheter placement but not its purpose. Choice D is incorrect as the PAC is not for the heart to heal but to monitor cardiac status.