Complex

Postoperatively, the nurse should monitor the patient who received inhalation anesthesia for which complication? -Tachypnea -Myoclonus -Hypertension -Laryngospasm

-Laryngospasm Possible complications of inhalation anesthetics include coughing, laryngospasm, and increased secretions.

Which nursing assessment of a 70-year-old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)? -Fluid balance -Apical pulse rate -Nutritional intake -Orientation and alertness

Apical pulse rate In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina or dysrhythmias. The medication also is expected to improve mental status and fluid balance and will increase metabolic rate and nutritional needs, but these changes will not result in potentially life-threatening complications.

An unresponsive patient who has type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemia syndrome (HHS). What should the nurse anticipate doing? -Giving 50% dextrose -Inserting an IV catheter -Initiating O2 by nasal cannula -Administering glargine (Lantus) insulin

Inserting an IV catheter HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires O2. Dextrose solutions will increase the patient's blood glucose and would be contraindicated.

Which assessment finding in a patient who had a bilateral adrenalectomy requires the most rapid action by the nurse? -The blood glucose is 192 mg/dL. -The lungs have bibasilar crackles. -The patient reports 6/10 incisional pain. -The blood pressure (BP) is 88/50 mm Hg.

The blood pressure (BP) is 88/50 mm Hg. The decreased BP indicates possible adrenal insufficiency. The nurse should immediately notify the health care provider so that corticosteroid medications can be administered. The nurse should also address the elevated glucose, incisional pain, and crackles with appropriate collaborative or nursing actions, but prevention and treatment of acute adrenal insufficiency are the priorities after adrenalectomy.

Both the electroencephalogram (EEG) monitor and the Bispectral Index Score (BIS) or Patient State Index (PSI) analyzer monitors are used to assess patient sedation levels in critically ill patients. The BIS and PSI monitors are simpler to use because they -can be used only on heavily sedated patients. -can be used only on pediatric patients. -provide raw EEG data and a numeric value. -require only five leads.

provide raw EEG data and a numeric value. The BIS and PSI have very simple steps for application, and results are displayed as raw EEG data and the numeric value. A single electrode is placed across the patient's forehead and is attached to a monitor. These monitors can be used in both children and adults and in patients with varying levels of sedation

The nurse is assessing a 22-yr-old patient experiencing the onset of symptoms of type 1 diabetes. To which question would the nurse anticipate a positive response? -"Are you anorexic?" -"Is your urine dark colored?" -"Have you lost weight lately?" -"Do you crave sugary drinks?"

"Have you lost weight lately?" Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute.

A patient scheduled to undergo total knee replacement surgery under general anesthesia asks the nurse, "Will the doctor put me to sleep with a mask over my face?" Which response by the nurse is most appropriate? -"Only your surgeon can tell you what method of anesthesia will be used." -"I will check with the anesthesia care provider to find out what is planned." -"General anesthesia is given by injecting drugs into your veins, so you will not need a mask over your face." -"Masks are no longer used for anesthesia. A tube inserted into your throat will deliver gas that puts you to sleep."

"I will check with the anesthesia care provider to find out what is planned." Routine general anesthesia is usually induced by the IV route with a hypnotic, anxiolytic, or dissociative agent. However, general anesthesia may be induced by IV or inhalation. The nurse should consult with the anesthesia care provider to determine the method selected for this patient. The anesthesia care provider will select the method of anesthesia, not the surgeon. Inhalation agents may be given through an endotracheal tube or a laryngeal mask airway.

A 40-year-old patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask? -"Have you had a recent head injury?" -"Do you have to wear larger shoes now?" -"Is there a family history of acromegaly?" -"Are you experiencing tremors or anxiety?"

-"Do you have to wear larger shoes now?" Acromegaly causes an enlargement of the hands and feet.

The nurse wishes to assess the quality of a patient's pain. Which of the following questions is appropriate to obtain this assessment if the patient is able to give a verbal response? -"Is the pain constant or intermittent?" -"Is the pain sharp, dull, or crushing?" -"What makes the pain better? Worse?" -"When did the pain start?"

"Is the pain sharp, dull, or crushing?" If the patient can describe the pain, the nurse can assess quality, such as sharp, dull, or crushing. The other responses relate to continuous or intermittent presence, what provides relief, and duration.

The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement supports the need to plan additional teaching? -"I frequently eat at restaurants, and my food has a lot of added salt." -"I had the flu earlier this week, so I couldn't take the hydrocortisone." -"I always double my dose of hydrocortisone on the days that I go for a long run." -"I take twice as much hydrocortisone in the morning dose as I do in the afternoon."

-"I had the flu earlier this week, so I couldn't take the hydrocortisone." The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given.

A 29-year-old woman with systemic lupus erythematosus has been prescribed 2 weeks of high-dose prednisone therapy. Which information about the prednisone is most important for the nurse to include? -"Weigh yourself daily to monitor for weight gain." -"The prednisone dose should be decreased gradually." -"A weight-bearing exercise program will help minimize risk for osteoporosis." -"Call the health care provider if you have mood changes with the prednisone."

-"The prednisone dose should be decreased gradually." Acute adrenal insufficiency may occur if exogenous corticosteroids are suddenly stopped. Mood alterations and weight gain are possible adverse effects of corticosteroid use, but these are not life-threatening effects. Osteoporosis occurs when patients take corticosteroids for longer periods.

Which question will the nurse in the endocrine clinic ask to help determine a patient's risk factors for goiter? -"How much milk do you drink?" -"What medications are you taking?" -"Have you had a recent neck injury?" -"Are your immunizations up to date?"

-"What medications are you taking?" Medications that contain thyroid-inhibiting substances can cause goiter.

After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? -A 70-year-old female patient taking levothyroxine (Synthroid) who has an irregular pulse of 134 -A 53-year-old male patient who has Addison's disease and is due for a prescribed dose of hydrocortisone (Solu-Cortef). -A 22-year-old male patient admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mEq/L -A 31 YO female patient with Cushing syndrome and a blood glucose level of 244 mg/dL

-A 70-year-old female patient taking levothyroxine (Synthroid) who has an irregular pulse of 134 Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias. The patient's high pulse rate needs rapid investigation by the nurse to assess for and intervene with any cardiac problems. The other patients also require nursing assessment and/or actions but are not at risk for life-threatening complications.

A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? -Plan for emergency tracheostomy. -Administer IV calcium gluconate. -Prepare for endotracheal intubation. -Begin thyroid hormone replacement

-Administer IV calcium gluconate. The patient's clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve the stridor. Thyroid hormone replacement may be needed eventually but will not improve the symptoms of hypocalcemia.

The following interventions are prescribed by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? -Give diphenhydramine -Administer epinephrine. -Start continuous ECG monitoring. -Draw blood for complete blood count.

-Administer epinephrine. Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones completed.

A 78-kg patient in septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. After initial fluid volume resuscitation, the patient's urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question? -Administer furosemide (Lasix) 40 mg IV. -Increase normal saline infusion to 250 mL/hr. -Give hydrocortisone (Solu-Cortef) 100 mg IV. -Use norepinephrine to keep systolic BP above 90 mm Hg.

-Administer furosemide (Lasix) 40 mg IV.

A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104° F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? -Acetaminophen (Tylenol) 650 mg rectally. -Administer normal saline IV at 500 mL/hr. -Start norepinephrine to keep blood pressure above 90 mm Hg. -Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.

-Administer normal saline IV at 500 mL/hr. Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate and should be initiated quickly as well.

A patient is admitted to the emergency department (ED) in shock of unknown etiology. What should be the nurse's first action? -Obtain the blood pressure. -Check the level of orientation. -Administer supplemental oxygen. -Obtain a 12-lead electrocardiogram.

-Administer supplemental oxygen. The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of O2 should be done first. The other actions should be done as rapidly as possible after providing O2.

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? -Check temperature every 2 hours. -Monitor breath sounds frequently. -Maintain patient in supine position. -Assess skin for flushing and itching.

-Monitor breath sounds frequently. Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital? (Select all that apply.) -Ambulate postoperative patients as soon as possible after surgery. -Use aseptic technique when manipulating invasive lines or devices. -Remove indwelling urinary catheters as soon as possible after surgery. -Administer prescribed antibiotics within 1 hour for patients with possible sepsis. -Advocate for parenteral nutrition for patients who cannot take in adequate calories.

-Ambulate postoperative patients as soon as possible after surgery. -Use aseptic technique when manipulating invasive lines or devices. -Remove indwelling urinary catheters as soon as possible after surgery. -Administer prescribed antibiotics within 1 hour for patients with possible sepsis.

Which information will the nurse teach a patient who has been newly diagnosed with Graves' disease? -Exercise is contraindicated to avoid increasing metabolic rate. -Restriction of iodine intake is needed to reduce thyroid activity. -Antithyroid medications may take several months for full effect. -Surgery will eventually be required to remove the thyroid gland.

-Antithyroid medications may take several months for full effect. Medications used to block the synthesis of thyroid hormones may take 2 to 3 months before the full effect is seen. Large doses of iodine are used to inhibit the synthesis of thyroid hormones. Exercise using large muscle groups is encouraged to decrease the irritability and hyperactivity associated with high levels of thyroid hormones. Radioactive iodine is the most common treatment for Graves' disease, although surgery may be used.

A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first? -Observe the dressing for bleeding. -Check the blood pressure and pulse. -Assess the patient's respiratory effort. -Support the patient's head with pillows.

-Assess the patient's respiratory effort. Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany. The priority nursing action is to assess the airway. The other actions are also part of the standard nursing care postthyroidectomy but are not as high of a priority.

A patient is scheduled for transsphenoidal hypophysectomy to treat a pituitary adenoma. What should the nurse include in preoperative teaching? -Cough and deep breathe every 2 hours postoperatively. -Remain on bed rest for the first 48 hours postoperatively. -Avoid brushing teeth for at least 10 days after the surgery. -You will be positioned flat with a cervical collar after surgery.

-Avoid brushing teeth for at least 10 days after the surgery. To avoid disruption of the suture line, the patient should avoid brushing the teeth for 10 days after surgery. It is not necessary to remain on bed rest after this surgery. Coughing is discouraged because it may cause leakage of cerebrospinal fluid (CSF) from the suture line. The head of the bed should be elevated 30 degrees to reduce pressure on the sella turcica and decrease the risk for headaches. A cervical collar is not needed.

The nurse is caring for a patient following an adrenalectomy. What is the highest priority in the immediate postoperative period? -Protecting the patient's skin -Monitoring for signs of infection -Balancing fluids and electrolytes -Preventing emotional disturbances

-Balancing fluids and electrolytes After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life threatening as the circulatory collapse that can occur with fluid and electrolyte disturbances.

A patient who had radical neck surgery to remove a malignant tumor developed hypoparathyroidism. What topic should the nurse plan to teach the patient? -Bisphosphonates to reduce bone demineralization -Calcium supplements to normalize serum calcium levels -Increasing fluid intake to decrease risk for nephrolithiasis -Including whole grains in the diet to prevent constipation

-Calcium supplements to normalize serum calcium levels Oral calcium supplements are used to maintain the serum calcium in normal range and prevent the complications of hypocalcemia. Whole grain foods decrease calcium absorption and will not be recommended. Bisphosphonates will lower serum calcium levels further by preventing calcium from being reabsorbed from bone. Kidney stones are not a complication of hypoparathyroidism and low calcium levels.

To evaluate the effectiveness of the pantoprazole (Protonix) given to a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? -Auscultate bowel sounds. -Ask the patient about nausea. -Check stools for occult blood. -Palpate for abdominal tenderness.

-Check stools for occult blood. Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done, but these will not help in determining the effectiveness of the pantoprazole administration.

The nurse is caring for a patient receiving intravenous ibuprofen for pain management. The nurse recognizes which laboratory assessment to be a possible side effect of the ibuprofen? -Creatinine: 3.1 mg/dL -Platelet count 350,000 billion/L -White blood count 13, 550 mm3 -ALT 25 U/L

-Creatinine: 3.1 mg/dL Ibuprofen can result in renal insufficiency, which may be noted in an elevated serum creatinine level. Thrombocytopenia (low platelet count) is another possible side effect. This platelet count is elevated. An elevated white blood count indicates infection. Although ibuprofen is cleared primarily by the kidneys, it is also important to assess liver function, which would show elevated liver enzymes, not low values such as shown here.

An 82-year-old patient in a long-term care facility is newly diagnosed with hypothyroidism. The nurse will need to consult with the health care provider before administering the prescribed -Docusate (Colace) -Ibuprofen (Motrin) -Diazepam (Valium) -Cefoxitin (Mefoxin)

-Diazepam (Valium) Worsening of mental status and myxedema coma can be precipitated using sedatives, especially in older adults. The nurse should discuss the use of diazepam with the health care provider before administration. The other medications may be given safely to the patient.

What action should the nurse take when providing care for a patient who has an adrenocortical adenoma causing hyperaldosteronism? -Check blood glucose level every 4 hours. -Monitor the blood pressure every 4 hours. -Elevate the patient's legs to relieve edema. -Order the patient a potassium-restricted diet.

-Monitor the blood pressure every 4 hours. Hypertension caused by sodium retention is a common complication of hyperaldosteronism. Hyperaldosteronism does not cause an elevation in blood glucose. The patient will be hypokalemic and require potassium supplementation before surgery. Edema does not usually occur with hyperaldosteronism.

Which nursing action will be included in the plan of care for a patient with Graves' disease who has exophthalmos? -Place cold packs on the eyes to relieve pain and swelling. -Elevate the head of the patient's bed to reduce periorbital fluid. -Apply alternating eye patches to protect the corneas from irritation. -Teach the patient to blink every few seconds to lubricate the corneas.

-Elevate the head of the patient's bed to reduce periorbital fluid. The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos, the patient is unable to close the eyes completely to blink. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring. The swelling of the eye is not caused by excessive blood flow to the eye, so cold packs will not be helpful.

A patient with primary hyperparathyroidism has a serum phosphorus level of 1.7 mg/dL (0.55 mmol/L) and calcium of 14 mg/dL (3.5 mmol/L). Which nursing action should be included in the plan of care? -Restrict the patient to bed rest. -Encourage 4000 mL of fluids daily. -Institute routine seizure precautions. -Assess for positive Chvostek's sign.

-Encourage 4000 mL of fluids daily. The patient with hypercalcemia is at risk for kidney stones, which may be prevented by a high fluid intake. Seizure precautions and monitoring for Chvostek's or Trousseau's sign are appropriate for hypocalcemic patients. The patient should engage in weight-bearing exercise to decrease calcium loss from bone.

A patient develops carpopedal spasms and tingling of the lips following a parathyroidectomy. Which action will provide the patient with rapid temporary relief from the symptoms? -Start the PRN O2 at 2 L/min per cannula. -Administer the prescribed muscle relaxant. -Have the patient rebreathe from a paper bag. -Stretch the muscles with passive range of motion

-Have the patient rebreathe from a paper bag. The patient's symptoms suggest mild hypocalcemia. The symptoms of hypocalcemia will be temporarily reduced by having the patient breathe into a paper bag, which will raise the PaCO2 and create a more acidic pH. Applying as-needed O2 or range of motion will have no impact on the ionized calcium level. Calcium supplements will be given to normalize calcium levels quickly, but oral supplements will take time to be absorbed.

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? -Inspiratory crackles -Heart rate 45 beats/min -Cool, clammy extremities -Temperature 101.2° F (38.4° C)

-Heart rate 45 beats/min Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse should contact the health care provider before administering levothyroxine (Synthroid)? -Increased thyroxine (T4) level -Blood pressure 112/62 mm Hg -Distant and difficult to hear heart sounds -Elevated thyroid stimulating hormone level

-Increased thyroxine (T4) level An increased thyroxine level indicates the levothyroxine dose needs to be decreased. The other data are consistent with hypothyroidism and the nurse should administer the levothyroxine.

A patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon? -Difficult to awaken. -Increasing neck swelling. -Reports 7/10 incisional pain. -Cardiac rate 112 beats/min.

-Increasing neck swelling. The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 beats/min is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Sleepiness in the immediate postoperative period is expected.

Which finding indicates to the nurse that the current therapies are effective for a patient who has acute adrenal insufficiency? -Increasing serum sodium levels -Decreasing blood glucose levels -Decreasing serum chloride levels -Increasing serum potassium levels

-Increasing serum sodium levels Clinical manifestations of Addison's disease include hyponatremia and an increase in sodium level indicates improvement. The other values indicate that treatment has not been effective.

A patient with diabetic ketoacidosis is brought to the emergency department. Which prescribed action should the nurse implement first? -Infuse 1 L of normal saline per hour. -Give sodium bicarbonate 50 mEq IV push. -Administer regular insulin 10 U by IV push. -Start a regular insulin infusion at 0.1 units/kg/hr.

-Infuse 1 L of normal saline per hour. The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids.

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients with shock, which action by the new RN indicates a need for more education? -Placing the pulse oximeter on the ear for a patient with septic shock -Keeping the head of the bed flat for a patient with hypovolemic shock -Maintaining a cool room temperature for a patient with neurogenic shock -Increasing the nitroprusside for a patient with cardiogenic shock and a high SVR

-Maintaining a cool room temperature for a patient with neurogenic shock Patients with neurogenic shock have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.

The nurse is planning postoperative care for a patient who is being admitted to the surgical unit from the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included? -Palpate extremities for edema. -Measure urine volume every hour. -Check hematocrit every 2 hours for 8 hours. -Monitor continuous pulse oximetry for 24 hours.

-Measure urine volume every hour. After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema. Monitoring of urine output and urine specific gravity is essential. Hemorrhage is not a common problem. There is no need to check the hematocrit hourly. The patient is at risk for dehydration, not volume overload. The patient is not at high risk for problems with oxygenation, and continuous pulse oximetry is not needed.

Which finding by the nurse when assessing a patient with a large pituitary adenoma is most important to report to the health care provider? -Changes in visual field -Milk leaking from breasts -Blood glucose 150 mg/dL -Nausea and projectile vomiting

-Nausea and projectile vomiting Nausea and projectile vomiting may indicate increased intracranial pressure, which will require rapid actions for diagnosis and treatment. Changes in the visual field, elevated blood glucose, and galactorrhea are common with pituitary adenoma, but these do not require rapid action to prevent life-threatening complications.

A patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? -New onset of confusion -Decreased bowel sounds -Heart rate 112 beats/min -Pale, cool, and dry extremities

-New onset of confusion The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.

Which finding by the nurse when assessing a patient with Hashimoto's thyroiditis and a goiter will require the most immediate action? -New-onset changes in the patient's voice -Elevation in the patient's T3 and T4 levels -Resting apical pulse rate 112 beats/mind. -Bruit audible bilaterally over the thyroid gland

-New-onset changes in the patient's voice Changes in the patient's voice indicate that the goiter is compressing the laryngeal nerve and may lead to airway compression

What topic should the nurse teach a patient who had a pituitary adenoma after the hypophysectomy? -Sodium restriction to prevent fluid retention -Insulin to maintain normal blood glucose levels -Oral corticosteroids to replace endogenous cortisol -Chemotherapy to prevent malignant tumor recurrence

-Oral corticosteroids to replace endogenous cortisol Antidiuretic hormone (ADH), cortisol, and thyroid hormone replacement will be needed for life after hypophysectomy. Without the effects of adrenocorticotropic hormone (ACTH) and cortisol, the blood glucose and serum sodium will be low unless cortisol is replaced. An adenoma is a benign tumor, and chemotherapy will not be needed.

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? -Heart rate -Orientation -Blood pressure -Oxygen saturation

-Oxygen saturation Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

Which information obtained by the nurse in the endocrine clinic about a patient who has been taking prednisone 40 mg daily for 3 weeks is most important to report to the health care provider? -Patient's blood pressure is 148/94 mm Hg. -Patient has bilateral 2+ pitting ankle edema. -Patient stopped taking the medication 2 days ago. -Patient has not been taking the prescribed vitamin D.

-Patient stopped taking the medication 2 days ago. Sudden cessation of corticosteroids after taking the medication for a week or more can lead to adrenal insufficiency, with problems such as severe hypotension and hypoglycemia. The patient will need immediate evaluation by the health care provider to prevent or treat adrenal insufficiency. The other information will also be reported but does not require rapid treatment.

After change-of-shift report in the progressive care unit, who should the nurse care for first? -Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases. -Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/min. -Patient with suspected urosepsis who has new prescriptions for urine and blood cultures and antibiotics. -Patient admitted with anaphylaxis 3 hours ago who has clear lung sounds and a blood pressure of 108/58 mm Hg.

-Patient with suspected urosepsis who has new prescriptions for urine and blood cultures and antibiotics. Antibiotics should be given within the first hour for patients who have sepsis or suspected sepsis to prevent progression to systemic inflammatory response syndrome and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not need immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually need treatment in patients with a spinal cord injury. The findings for the patient admitted with anaphylaxis show resolution of bronchospasm and hypotension.

The cardiac telemetry unit charge nurse receives status reports from other nursing units about four patients who need cardiac monitoring. Which patient should be transferred to the cardiac unit first? -Patient with Hashimoto's thyroiditis and a heart rate of 102 -Patient with tetany who has a new order for IV calcium chloride -Patient with Cushing syndrome and a blood glucose of 140 mg/dL -Patient with Addison's disease who takes IV hydrocortisone twice daily

-Patient with tetany who has a new order for IV calcium chloride Emergency treatment of tetany requires IV administration of calcium; electrocardiographic monitoring will be required because cardiac arrest may occur if high calcium levels result from too-rapid administration.

A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take? (Select all that apply.) -Prepare to administer atropine IV. -Obtain baseline body temperature. -Infuse large volumes of lactated Ringer's solution. -Provide high-flow O2 (100%) by nonrebreather mask. -Prepare for emergent intubation and mechanical ventilation.

-Prepare to administer atropine IV. -Obtain baseline body temperature. -Provide high-flow O2 (100%) by nonrebreather mask. -Prepare for emergent intubation and mechanical ventilation. All the actions are appropriate except to give large volumes of lactated Ringer's solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because an ischemic liver cannot convert lactate to bicarbonate.

Which prescribed medication should the nurse expect will have rapid effects on a patient admitted to the emergency department in thyroid storm? -Iodine -Methimazole -Propylthiouracil -Propranolol (Inderal)

-Propranolol (Inderal) -Adrenergic blockers work rapidly to decrease the cardiovascular manifestations of thyroid storm. The other medications take days to weeks to have an impact on thyroid function.

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention prescribed by the health care provider should the nurse implement first? -Insert two large-bore IV catheters. -Provide O2 at 100% per non-rebreather mask. -Draw blood to type and crossmatch for transfusions. -Initiate continuous electrocardiogram (ECG) monitoring.

-Provide O2 at 100% per non-rebreather mask. The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize O2 delivery have been implemented.

A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving. Discharge is expected to occur in 2 days. Which teaching strategy is likely to result in effective patient self-management at home? -Delay teaching until closer to discharge date. -Provide written reminders of information taught. -Offer multiple options for management of therapies. -Ensure privacy for teaching by asking the family to leave.

-Provide written reminders of information taught. Written instructions will be helpful to the patient because initially the hypothyroid patient may be unable to remember to take medications and other aspects of self-care. Because the treatment regimen is complex, teaching should be started well before discharge. Family members or friends should be included in teaching because the hypothyroid patient is likely to forget some aspects of the treatment plan. A simpler regimen will be easier to understand until the patient is euthyroid.

A patient is being admitted with a diagnosis of Cushing syndrome. Which finding will the nurse expect during the assessment? -Chronically low blood pressure -Bronzed appearance of the skin -Purplish streaks on the abdomen -Decreased axillary and pubic hair

-Purplish streaks on the abdomen Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison's disease. Decreased axillary and pubic hair occur with androgen deficiency.

The best way to monitor agitation and effectiveness of treating it in the critically ill patient is to use a/the: -Confusion Assessment Method (CAM-ICU). -FACES assessment tool. -Glasgow Coma Scale. -Richmond Agitation Sedation Scale.

-Richmond Agitation Sedation Scale. Various sedation scales are available to assist the nurse in monitoring the level of sedation and assessing response to treatment. The Richmond Agitation Sedation Scale is a commonly used tool that has been validated. The CAM-ICU assesses for delirium. The FACES scale assesses pain. The Glasgow Coma Scale assesses neurological status.

A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective? -No heart murmur -Skin is warm and pink -Decreased troponin level -Blood pressure of 92/40 mm Hg

-Skin is warm and pink Warm, pink, and dry skin indicates that perfusion to tissues is improved. Because nitroprusside is a vasodilator, the blood pressure may be low even if the drug is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.

Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a patient's dislocated shoulder. What action does the nurse anticipate? -Starting an IV in the patient's unaffected arm -Securing an airtight fit for the inhalation mask -Preparing for placement of an epidural catheter -Giving deep sedation under physician supervision

-Starting an IV in the patient's unaffected arm

A patient who has hyperthyroidism is treated with radioactive iodine (RAI). What information should the nurse include in discharge teaching? -Take radioactive precautions with all body secretions. -Symptoms of hyperthyroidism should be relieved in about a week. -Symptoms of hypothyroidism will occur as the RAI therapy takes effect. -Discontinue the antithyroid medications that were taken before the RAI therapy.

-Symptoms of hypothyroidism will occur as the RAI therapy takes effect. There is a high incidence of post radiation hypothyroidism after RAI, and the patient should be monitored for symptoms of hypothyroidism. RAI has a delayed response, with the maximum effect not seen for 2 to 3 months, and the patient will continue to take antithyroid medications during this time. The therapeutic dose of radioactive iodine is low enough that no radiation safety precautions are needed.

Which assessment finding for an adult admitted with Graves' disease requires the most rapid intervention by the nurse? -Heart rate 136 beats/min -Severe bilateral exophthalmos -Temperature 103.8° F (40.4° C) -Blood pressure 166/100 mm Hg

-Temperature 103.8° F (40.4° C) The patient's temperature indicates that the patient may have thyrotoxic crisis and that interventions to lower the temperature are needed immediately. The other findings also require intervention but do not indicate potentially life-threatening complications.

Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to contact the health care provider? -The patient's urine output is 18 mL/hr. -The patient's heart rate is 110 beats/min. -The patient's peripheral pulses are weak. -The patient reports diffuse chest pressure.

-The patient reports diffuse chest pressure. Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion and cause chest pain or pressure. Low urine output, weal pulses, and tachycardia are consistent with the patient's diagnosis. They and should be reported to the health care provider but do not require an immediate need for a change in therapy.

Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which data indicate that the nurse should consult with the health care provider before starting the norepinephrine? -The patient is receiving low dose dopamine. -The patient's central venous pressure is 3 mm Hg. -The patient is in sinus tachycardia at 120 beats/min. -The patient has had no urine output since admission.

-The patient's central venous pressure is 3 mm Hg. Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? -The patient's serum creatinine level is high. -The patient reports intermittent chest pressure. -The patient's extremities are cool, and pulses are 1+. -The patient has bilateral crackles throughout lung fields.

-The patient's serum creatinine level is high. The high serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all symptoms consistent with the patient's diagnosis of cardiogenic shock.

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? -There are no signs of hemorrhage. -Hemoglobin is within normal limits. -Urine output 65 mL over the past hour. -Mean arterial pressure (MAP) is 72 mm Hg.

-Urine output 65 mL over the past hour. Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion. The absence of hemorrhage helps to prevent further fluid loss but does not reflect fluid balance.

A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the postanesthesia care unit (PACU), what assessment finding is most important for the nurse to report? -Lethargy -Report of nausea -Disorientation to time -Weak chest movement

-Weak chest movement The most serious adverse effect of the neuromuscular blocking agents is weakness of the respiratory muscles, which can lead to postoperative hypoxemia. Nausea, lethargy, and disorientation are possible adverse effects of anesthetic drugs, but they are not as great of concern as respiratory depression.

A patient requires pancuronium as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes: (Select all that apply.) -administration of sedatives concurrently with neuromuscular blockade. -dangling the patient's feet over the edge of the bed and assisting the patient to sit up in a chair at least twice each day. -ensuring that deep vein thrombosis prophylaxis is initiated. -providing interventions for eye care, oral care, and skin care. -ensuring good nutrition with frequent feedings throughout the day.

-administration of sedatives concurrently with neuromuscular blockade. -ensuring that deep vein thrombosis prophylaxis is initiated. -providing interventions for eye care, oral care, and skin care. Pancuronium is a neuromuscular blocking agent (NMB) resulting in complete paralysis of the patient. Patients receiving NMB must be provided total care, including eye, skin, and oral care interventions. Patients are at high risk for deep vein thrombosis secondary to drug-induced paralysis and bed rest. Sedatives must be administered concurrently with NMB, because NMBs have no sedative effects. Although many critically ill patients are assisted to the chair, chair activity is not appropriate for patients receiving NMB; passive exercise is most appropriate. Feeding the patient on an NMB orally is not possible.

The nurse is assessing pain levels in a critically ill patient using the Behavioral Pain Scale. The nurse recognizes __________ as indicating the greatest level of pain. -brow lowering -eyelid closing -grimacing -relaxed facial expression

-grimacing The Behavioral Pain Scale issues the most points, indicating the greatest amount of pain, to assessment of facial grimacing.

The nurse is caring for a postoperative patient in the critical care unit. The physician has ordered patient-controlled analgesia (PCA) for the patient. The nurse understands that the PCA: (Select all that apply.) -is a safe and effective method for administering analgesia. -has potentially fewer side effects than other routes of analgesic administration. -is an ideal method to provide most critically ill patients some control over their treatment -provides good quality analgesia -does not work well without family assistance.

-is a safe and effective method for administering analgesia. -has potentially fewer side effects than other routes of analgesic administration. -provides good quality analgesia PCA is safe and effective, provides good-quality analgesia, and has potentially fewer side effects than other routes. PCA management is rarely appropriate for critically ill patients because most patients are unable to depress the button, or they are too ill to manage their pain effectively. If the patient is cognitively intact, family assistance is not needed to use this modality and is not advisable; the patient needs to be able to push the button.

After change-of-shift report, which patient will the nurse assess first? -A 19-yr-old patient with type 1 diabetes who was admitted with dawn phenomenon -A 35-yr-old patient with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL -A 68-yr-old patient with type 2 diabetes who has severe peripheral neuropathy and reports burning foot pain -A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa

A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa The patient's diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed. The other patients also need assessment and intervention but do not have life-threatening complications.

While in the holding area, a patient reveals to the nurse that his father had a high fever after surgery. What action by the nurse is a priority? -Place a medical alert sticker on the front of the patient's chart. -Alert the anesthesia care provider of the family member's reaction to surgery. -Give 650 mg of acetaminophen (Tylenol) per rectum as a preventive measure. -Reassure the patient that his temperature will be monitored closely after surgery.

Alert the anesthesia care provider of the family member's reaction to surgery. The anesthesia care provider (ACP) needs to be notified and made aware of the patient's family history of anesthesia reactions. Malignant hyperthermia (MH) is a valid concern because the patient's father appears to have had a reaction to surgery.

A 26-yr-old female who has type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and reports a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. What should the nurse advise the patient to do? -Use only the lispro insulin until the symptoms are resolved. -Limit intake of calories until the glucose is less than 120 mg/dL. -Monitor blood glucose every 4 hours and contact the clinic if it rises. -Decrease carbohydrates until glycosylated hemoglobin is less than 7%.

Monitor blood glucose every 4 hours and contact the clinic if it rises. Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with lispro insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to diabetic ketoacidosis (DKA). Decreasing carbohydrate or caloric intake is not appropriate because the patient will need more calories when ill. Glycosylated hemoglobin testing is not used to evaluate short-term alterations in blood glucose.

After a patient who has septic shock receives 2 L of normal saline intravenously, the central venous pressure is 10 mm Hg and the blood pressure is 82/40 mm Hg. What medication should the nurse anticipate? -Furosemide -Nitroglycerin -Norepinephrine -Sodium nitroprusside

Norepinephrine When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR.

When caring for a patient who has received a general anesthetic, the circulating nurse notes red, raised wheals on the patient's arms. Which action should the nurse take? -Apply lotion to the affected areas. -Cover the arms with sterile drapes. -Recheck the patient's arms during surgery. -Notify the anesthesia care practitioner (ACP).

Notify the anesthesia care practitioner (ACP). The presence of wheals indicates a possible allergic or anaphylactic reaction, which may have been caused by latex or by medications administered as part of general anesthesia. Because general anesthesia may mask anaphylaxis, the nurse should report this to the ACP. The other actions are not appropriate at this time.

A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first? -Infuse dextrose 50% by slow IV push. -Administer 1 mg glucagon subcutaneously. -Obtain a glucose reading using a finger stick. -Have the patient drink 4 ounces of orange juice.

Obtain a glucose reading using a finger stick. The patient's clinical manifestations are consistent with hypoglycemia, and the initial action should be to check the patient's glucose with a finger stick or order a stat blood glucose.

A 27-yr-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first? -Place the patient on a cardiac monitor. -Administer IV potassium supplements. -Ask the patient about home insulin doses. -Start an insulin infusion at 0.1 units/kg/hr.

Place the patient on a cardiac monitor. Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring because insulin infusion will further decrease potassium levels. Discussion of home insulin and possible causes can wait until the patient is stabilized.

The nurse recognizes that which patient is likely to benefit most from patient-controlled analgesia (PCA)? -Patient with a C4 fracture and quadriplegia -Patient with a femur fracture and closed head injury -Postoperative patient who had elective bariatric surgery -Postoperative cardiac surgery patient with mild dementia

Postoperative patient who had elective bariatric surgery The patient undergoing bariatric surgery (an elective procedure) is the best candidate for PCA as this patient should be awake, cognitively intact, and will have the acute pain related to the surgical procedure. The quadriplegic would be unable to operate the PCA pump. The cardiac surgery patient with mild dementia may not understand how to operate the pump. Likewise, the patient with the closed head injury may not be cognitively intact.

Which action will the perioperative nurse take after surgery is completed for a patient who received ketamine as an anesthetic agent? -Question the order for giving a benzodiazepine. -Ensure that atropine is available in case of bradycardia. -Provide a quiet environment in the postanesthesia care unit. -Anticipate the need for higher than usual doses of analgesic agents.

Provide a quiet environment in the postanesthesia care unit. Hallucinations are an adverse effect associated with the dissociative anesthetics such as ketamine. Therefore, the postoperative environment should be kept quiet to decrease the risk of hallucinations. Because ketamine causes profound analgesia lasting into the postoperative period, higher doses of analgesics are not needed. Ketamine causes an increase in heart rate. Benzodiazepine may be used with ketamine to decrease the incidence of hallucinations and nightmares.

A 44-year-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be helpful for the patient problem of disturbed body image related to changes in appearance? -Reassure the patient that the physical changes are very common in patients with Cushing syndrome. -Discuss the use of diet and exercise in controlling the weight gain associated with Cushing syndrome. -Teach the patient that the metabolic impact of Cushing syndrome is of more importance than appearance. -Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery.

Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery. The most reassuring and accurate communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively. Reassurance that the physical changes are expected or that there are more serious physiologic problems associated with Cushing syndrome minimize the patient's concerns. The patient's physiological changes are caused by the high hormone levels, not by the patient's diet or exercise choices.

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? -Skin cool and clammy -Heart rate of 118 beats/min -Blood pressure of 92/56 mm Hg -O2 saturation of 93% on room air

Skin cool and clammy Because patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information will also be reported but does not indicate deterioration of the patient's status.

A 28-yr-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching? -The patient always carries hard candies when engaging in exercise. -The patient goes for a vigorous walk when his glucose is 200 mg/dL. -The patient has a peanut butter sandwich before going for a bicycle ride. -The patient increases daily exercise when ketones are present in the urine.

The patient increases daily exercise when ketones are present in the urine. When the patient is ketotic, exercise may result in an increase in blood glucose level. Patients with type 1 diabetes should be taught to avoid exercise when ketosis is present.

Which patient action indicates an accurate understanding of the nurse's teaching about the use of an insulin pump? -The patient programs the pump for an insulin bolus after eating. -The patient changes the location of the insertion site every week. -The patient takes the pump off at bedtime and starts it again each morning. -The patient plans a diet with more calories than usual when using the pump.

The patient programs the pump for an insulin bolus after eating In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake. The insertion site should be changed every 2 or 3 days. There is more flexibility in diet and exercise when an insulin pump is used, but it does not provide for consuming a higher calorie diet. The pump will deliver a basal insulin rate 24 hours a day.

A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? -The patient's heart rate is 58 beats/min. -The patient's extremities are warm and dry. -The patient's IV infusion site is cool and pale. -The patient's urine output is 28 mL over the past hour.

The patient's IV infusion site is cool and pale. The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the drug into a central line. An apical pulse of 58 beats/min is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action.

The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis? -Glasgow Coma Scale score of 3 -Train-of-four yields two twitches -Bispectral index of 60 -CAM-ICU positive

Train-of-four yields two twitches A train-of-four response of two twitches (out of four) using a peripheral nerve stimulator indicates adequate paralysis. The Glasgow Coma Scale does not assess paralysis; it is an indicator of consciousness. The bispectral index provides an assessment of sedation. The CAM-ICU is a tool to assess delirium.

The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. What should the nurse obtain in preparation for the patient's arrival? -A dopamine infusion -A hypothermia blanket -Lactated Ringer's solution -Two 16-gauge IV catheters

Two 16-gauge IV catheters A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large-bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and would not be prescribed until the patient has been assessed for liver abnormalities. Vasopressor infusion is not used as th

Nociceptors differ from other nerve receptors in the body in that they: -adapt very little to continual pain response. -inhibit the infiltration of neutrophils and eosinophils. -play no role in the inflammatory response. -transmit only the thermal stimuli.

adapt very little to continual pain response. Nociceptors are stimulated by mechanical, chemical, or thermal stimuli. Nociceptors differ from other nerve receptors in the body in that they adapt very little to the pain response. The body continues to experience pain until the stimulus is discontinued or therapy is initiated. This is a protective mechanism so that the body tissues being damaged will be removed from harm. Nociceptors usually initiate inflammatory responses near injured capillaries. As such, the response promotes infiltration of injured tissues with neutrophils and eosinophils.

The most important nursing intervention for patients who receive neuromuscular blocking agents is to -administer sedatives in conjunction with the neuromuscular blocking agents. -assess neurological status every 30 minutes. -avoid interaction with the patient, because he or she won't be able to hear. -restrain the patient to avoid self-extubation.

administer sedatives in conjunction with the neuromuscular blocking agents. Neuromuscular blocking agents cause paralysis only; they do not cause sedation. Therefore, concomitant administration of sedatives is essential. Neurological status is monitored according to unit protocol. Nurses should communicate with all critically ill patients, regardless of their status. If the patient is paralyzed, restraining devices may not be needed.

A postsurgical patient is on a ventilator in the critical care unit. The patient has been tolerating the ventilator well and has not required any sedation. On assessment, the nurse notes the patient is tachycardic and hypertensive with an increased respiratory rate of 28 breaths/min. The patient has been suctioned recently via the endotracheal tube, and the airway is clear. The patient responds appropriately to the nurse's commands. The nurse should: -assess the patient's level of pain. -decrease the ventilator rate. -provide sedation as ordered. -suction the patient again.

assess the patient's level of pain.

The assessment of pain and anxiety is a continuous process. When critically ill patients exhibit signs of anxiety, the nurse's first priority is to -administer antianxiety medications as ordered. -administer pain medication as ordered. -identify and treat the underlying cause. -reassess the patient hourly to determine whether symptoms resolve on their own.

identify and treat the underlying cause. When patients exhibit signs of anxiety or agitation, the first priority is to identify and treat the underlying cause, which could be hypoxemia, hypoglycemia, hypotension, pain, or withdrawal from alcohol and drugs. Treatment is not initiated until assessment is completed. Medication may not be needed if the underlying cause can be resolved.

The nurse is caring for a patient who requires administration of a neuromuscular blocking agent to facilitate ventilation with nontraditional modes. The nurse understands that neuromuscular blocking agents provide: -antianxiety effects. -complete analgesia. -high levels of sedation. -no sedation or analgesia.

no sedation or analgesia. Neuromuscular blocking (NMB) agents do not possess any sedative or analgesic properties. Patients who receive NMBs must also receive sedatives and pain medication.

The primary mode of action for neuromuscular blocking agents used in the management of some ventilated patients is -analgesia. -anticonvulsant therapy. -paralysis. -sedation.

paralysis These agents cause respiratory muscle paralysis. They do not provide analgesia or sedation. They do not have anticonvulsant properties

The nurse is concerned that the patient will pull out the endotracheal tube. As part of the nursing management, the nurse obtains an order for -arm binders or splints. -a higher dosage of lorazepam. -propofol. - soft wrist restraints.

soft wrist restraints. The priority in caring for agitated patients is safety. The least restrictive methods of keeping the patient safe are appropriate. IfNpUoRssSiIbNlGe,TtBh.eCtOuMbe or device causing irritation should be removed, but if that is not possible, the nurse must prevent the patient from pulling it out. Restraints are associated with an increased incidence of agitation and delirium. Therefore, restraints should not be used unless as a last resort for combative patients. The least amount of sedation is also recommended; therefore, neither increasing the dosage of lorazepam nor adding propofol is indicated and would be likely to prolong mechanical ventilation.

The nurse is caring for a patient receiving a benzodiazepine intermittently. The nurse understands that the best way to administer such drugs is to: -administer around the clock, rather than as needed, to ensure constant sedation. -administer the medications through the feeding tube to prevent complications. -give the highest allowable dose for the greatest effect. -titrate to a predefined endpoint using a standard sedation scale.

titrate to a predefined endpoint using a standard sedation scale. The best approach for administering benzodiazepines (and all sedatives) is to administer and titrate to a desired endpoint using a standard sedation scale. Administering around the clock as well as giving the highest allowable dose without basing it on an assessment target may result in excessive sedation. For greatest effect, most benzodiazepines are given intravenously.