The patient is on intake and output (I&O), as well as daily weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should

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Question 1 of 9

The patient is on intake and output (I&O), as well as daily weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should

Correct Answer: C

Rationale: First, the nurse should assess the patient's lungs to rule out any potential respiratory issues causing fluid retention. This is crucial as the patient has signs of fluid imbalance with decreased output and increased weight. Assessing the lungs can help identify conditions like heart failure or pneumonia that may contribute to these changes. Drawing a trough level (choice A) is not a priority as it doesn't address the immediate concern of fluid imbalance. Placing the patient on fluid restriction (choice B) should only be done after identifying the cause of the imbalance. Inserting an indwelling catheter (choice D) is not necessary at this point as the issue is related to fluid balance, not urinary elimination.

Question 2 of 9

What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period?

Correct Answer: C

Rationale: The correct answer is C: Primary nursing. Primary nursing is a care delivery model where one nurse is responsible for the total care of a group of clients over a 24-hour period. This promotes continuity of care, individualized attention, and better nurse-client relationships. In primary nursing, the nurse plans and directs care, coordinates with other healthcare team members, and serves as the main point of contact for the clients. A: Case management involves coordinating care across different healthcare providers and services, not necessarily focusing on a specific group of clients over a 24-hour period. B: Team nursing involves a team of healthcare providers working together to deliver care, rather than one nurse being responsible for a specific group of clients over a 24-hour period. D: Functional nursing divides tasks among different healthcare team members based on their specific skills, which may not provide the same level of continuity and individualized care as primary nursing.

Question 3 of 9

The nurse is caring for a patient receiving continuous norepinephrine (Levophed) IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted?

Correct Answer: B

Rationale: The correct answer is B because a low Mean Arterial Pressure (MAP) indicates inadequate perfusion, which may require adjusting the norepinephrine infusion rate to increase blood pressure. A: A heart rate of 58 beats/minute is within a normal range and may not necessarily indicate a need for adjustment. C: Elevated Systemic Vascular Resistance (SVR) may be an expected response to norepinephrine and does not necessarily indicate a need for adjustment. D: A low Pulmonary Artery Wedge Pressure (PAWP) may indicate fluid volume deficit but does not directly relate to the need for adjusting norepinephrine infusion rate.

Question 4 of 9

Which statement is a likely response from someone who h as survived a stay in the critical care unit?

Correct Answer: A

Rationale: Rationale: Choice A is the correct answer because it reflects a positive attitude towards potential future treatments in the critical care unit and gratitude for being able to see family again. The survivor acknowledges the past experience but remains optimistic. Summary: - Choice B is incorrect as it shows a strong aversion to hospital care, indicating a preference for death over treatment. - Choice C is incorrect as it focuses on the family's reaction and not the survivor's personal experience or perspective. - Choice D is incorrect as it highlights a trivial aspect (eating) rather than reflecting on the ICU experience or future treatments.

Question 5 of 9

A nurse who works in an intermediate care unit has experienced high nursing turnover. The nurse manager is often considered to be an autocratic leade r by staff members and that leadership style is contributing to turnover. The nurse asks to be involved in developing new guidelines to prevent pressure ulcers in the patient populat ion. The nurse manager suggests that the nurse has not yet had enough experience to be on tahbierb p.croemv/teenstt ion task force. This situation and setting is an example of what form of ineffec tive leadership?

Correct Answer: C

Rationale: The correct answer is C: Displaying ineffective decision making. In this scenario, the nurse manager's decision to exclude the nurse from participating in developing new guidelines is an example of ineffective decision making. By dismissing the nurse's request based on lack of experience rather than considering their input and involvement, the manager is not utilizing the nurse's expertise and potentially missing out on valuable insights. This decision reflects a lack of inclusivity, collaboration, and respect for the nurse's professional growth and potential contributions. The other choices are not directly applicable in this context as the core issue lies in the manager's decision-making process.

Question 6 of 9

The nurse is caring for a patient who sustained a head injury and is unresponsive to painful stimuli. Which intervention is most appropriate while bathaibnirgb. ctohme/ tpesatt ient?

Correct Answer: B

Rationale: The correct answer is B: Because the patient is unconscious, complete care as quickly and quietly as possible. This is the most appropriate intervention as it prioritizes the patient's comfort and minimizes unnecessary stimulation. Performing care quickly reduces the time the patient is exposed to potentially uncomfortable procedures. Being quiet also helps create a calming environment for the patient, which is important for someone who is unresponsive. Explanation for other choices: A: Asking a family member to help and discussing family structure is not appropriate as it can be intrusive and may not be relevant or beneficial to the patient's care. C: Informing the patient of the day and time is unnecessary as the patient is unresponsive. Providing care is more crucial than updating the patient. D: Turning on the television is inappropriate as it introduces unnecessary noise and distraction, which can be overwhelming for an unresponsive patient.

Question 7 of 9

Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? (Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A, hypotension. During hemodialysis for acute kidney injury, fluid removal can lead to hypotension due to rapid changes in blood volume. This can cause dizziness, weakness, and even loss of consciousness. Dysrhythmias (choice B) are less common but can occur due to electrolyte imbalances. Muscle cramps (choice C) may occur during or after dialysis due to electrolyte imbalances or fluid shifts, but they are not as common as hypotension. Hemolysis (choice D) is not a common complication of hemodialysis for acute kidney injury, as it is more commonly associated with issues related to the dialysis machine or blood tubing.

Question 8 of 9

The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include whic h intervention?

Correct Answer: D

Rationale: The correct answer is D: Mobility. Maintaining mobility helps prevent blood stasis, a leading factor in the development of pulmonary embolism. Movement promotes circulation, reducing the risk of blood clots. A: Antiseptic oral care is important for oral hygiene but not directly related to preventing pulmonary embolism. B: Bed rest with head of bed elevated can actually increase the risk of clots due to immobility. C: Coughing and deep breathing are beneficial for preventing respiratory complications but do not address the underlying cause of pulmonary embolism.

Question 9 of 9

The nurse is caring for a patient with acute kidney injury who is being treated with hemodialysis. The patient asks if he will need dialysis for the rest of his life. Which of the following would be the best response?

Correct Answer: D

Rationale: The correct answer is D: “Recovery is possible, but it may take several months.” This response is the best choice as it provides a balanced and accurate explanation to the patient. Here's the rationale: 1. Hemodialysis is often used as a temporary measure to support kidney function while allowing time for the kidneys to recover. 2. Acute kidney injury can be reversible in some cases, especially if the underlying cause is identified and treated promptly. 3. Recovery time varies for each individual, and it can indeed take several months for kidney function to improve. 4. Choices A, B, and C are incorrect: - A is overly pessimistic and does not consider the potential for recovery. - B provides a specific timeframe that may not be accurate for all patients. - C is not a reliable indicator of kidney function recovery and may lead to confusion.

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