When fluid is present in the alveoli what is the result?

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Question 1 of 9

When fluid is present in the alveoli what is the result?

Correct Answer: A

Rationale: The correct answer is A: Alveoli collapse and atelectasis occurs. When fluid is present in the alveoli, it impairs the surface tension necessary for the alveoli to remain open, leading to collapse and atelectasis. This prevents proper gas exchange, resulting in hypoxemia. Choice B is incorrect because impaired gas diffusion typically occurs with conditions affecting the alveolar-capillary membrane, not fluid in the alveoli. Choice C is incorrect as hypoventilation refers to decreased ventilation, not specifically related to fluid in the alveoli. Choice D is incorrect as fluid in the alveoli is not a direct indicator of heart failure.

Question 2 of 9

Her urine output for the past 2 hours totaled only 40 mL. She arrived from s urgery to repair an aortic aneurysm 4 hours ago and remains on mechanical ventilation. In the past 2 hours, her heart rate has increased from 80 to 100 beats per minute and he r blood pressure has decreased from 128/82 to 100/70 mm Hg. She is being given an infusaiboirnb .coofm n/toesrtm al saline at 100 mL per hour. Her right atrial pressure through the subclavian cen tral line is low at 3 mm Hg. Her urine is concentrated. Her BUN and creatinine levels have been stable and in normal range. Her abdominal dressing is dry with no indication of bleeding. My assessment suggests that Mrs. P. is hypovolemic and I would like you to consider in creasing her fluids or giving her a fluid challenge. Using the SBAR model for communication, the information the nurse gives about the patient’s history and vital signs is appropriate fo r what part of the model?

Correct Answer: C

Rationale: The correct answer is C: Assessment. In the SBAR communication model, the nurse's information about the patient's history and vital signs falls under the Assessment component. This is because the nurse is providing a detailed evaluation of the patient's current condition based on objective data such as urine output, heart rate, blood pressure, and other key indicators. The nurse is analyzing the situation and forming a judgment that the patient is hypovolemic, indicating a fluid deficit. This assessment is crucial for informing further actions or interventions, such as increasing fluids or providing a fluid challenge. Summary of other choices: A: Situation - This choice would refer to a brief summary of the current situation without detailed analysis or interpretation. B: Background - This choice would involve providing relevant background information about the patient, such as medical history or recent procedures, but not the current assessment of the patient's condition. D: Recommendation - This choice would involve suggesting a course of action or treatment based on the assessment, which comes after

Question 3 of 9

The nurse is caring for a very seriously ill patient in the CCU. The family visits sporadically, stays for only a short time, and does not ask many questions. How could the nurse best begin to involve the family in the patients care?

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.

Question 4 of 9

The amount of effort needed to maintain a given level of ventilation is referred to using what term?

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.

Question 5 of 9

Palliation care includes what goals? (Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A (Pain relief) because palliative care aims to provide comfort and improve the quality of life for individuals with serious illnesses. Pain relief is a crucial goal in palliative care to alleviate physical suffering. Nausea relief (B) is also commonly addressed in palliative care, but it is not a universal goal. Psychological support (C) is an important aspect of palliative care but is not always a primary goal. Withdrawal of life-support interventions (D) is not a goal of palliative care, as palliative care focuses on symptom management and improving quality of life, not hastening death.

Question 6 of 9

Which scenarios contribute to effective handoff communicaabitribo.cno ma/tte csth ange of shift? (Select all that apply.)

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.

Question 7 of 9

What nursing strategies help families cope with the stress of critical illness? (Select all that apply.)

Correct Answer: B

Rationale: The correct answer is B: Encouraging family members to make notes of questions they have for the physician during family rounds. This strategy helps families cope with the stress of critical illness by empowering them to stay informed and actively participate in the patient's care. By encouraging them to make notes, it promotes effective communication with the healthcare team and ensures that their concerns and questions are addressed promptly. Other choices are incorrect: A: Asking the family to leave during the morning bath to promote the patient’s privacy is not a helpful strategy for coping with stress as it may lead to feelings of isolation and lack of involvement in the patient's care. C: Providing continuity of nursing care is important but may not directly address the family's coping mechanisms during a critical illness. D: Providing a daily update of the patient’s condition to the family spokesperson is valuable but may not fully address the family's need for active participation and communication with the healthcare team.

Question 8 of 9

A 45-year-old postsurgical patient is on a ventilator in the critical care unit has been tolerating the ventilator well and has not required any sedation. The apbairtbi.ecnomt /bteesct omes tachycardic and hypertensive with a respiratory rate that has increased to 28 breaths/min. The ventilator is set on synchronized intermittent mandatory ventilation (SIMV ) at a rate of 10 breaths/min. The patient has been suctioned recently via existing endotracheal tube until airway is clear. When the patient responds appropriately to the nurse’s command s, what should be the nurse’s priority intervention?

Correct Answer: A

Rationale: The correct answer is A: Assessing the patient's level of pain. In this situation, the patient's tachycardia, hypertension, and increased respiratory rate could be indicative of pain. By assessing the patient's pain level, the nurse can address any discomfort the patient may be experiencing, which could be contributing to these physiological responses. Summary of other choices: B: Decreasing the SIMV rate on the ventilator - This is not the priority intervention as the patient's symptoms are more likely related to pain rather than the ventilator settings. C: Providing sedation as ordered - Sedation is not the priority in this case as the patient has been tolerating the ventilator well without requiring sedation. D: Suctioning the patient again - Since the airway has been recently cleared, suctioning again is not necessary at this point and would not address the underlying cause of the patient's symptoms.

Question 9 of 9

Which of the following patients is at the greatest risk of developing acute kidney injury? A patient who

Correct Answer: D

Rationale: The correct answer is D because a patient with a history of fluid overload due to heart failure is at the greatest risk of developing acute kidney injury. Heart failure can lead to decreased kidney perfusion causing acute kidney injury. In this scenario, the patient's fluid overload exacerbates the situation, further compromising kidney function. Choice A is incorrect as aminoglycosides can cause kidney injury but the duration of 6 days is less concerning compared to chronic fluid overload from heart failure in choice D. Choice B is incorrect because controlled hypertension does not directly increase the risk of acute kidney injury. Choice C is incorrect as the patient being discharged 2 weeks earlier after aminoglycoside therapy does not necessarily indicate a higher risk compared to chronic fluid overload.

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