Which intervention promotes a more normal V/Q match for a client receiving mechanical ventilation?
A. Administering the prescribed muscle-paralyzing agents
B. Positioning the client so that the healthier lung is dependent to the more diseased lung
C. Ensuring that the pilot balloon on the endotracheal tube cuff is inflated to its maximal pressure
D. Auscultating the lungs bilaterally every 4 hours for the presence of crackles, wheezes, and other abnormal breath sounds
B
Clients who are being mechanically ventilated are experiencing a problem in which their normal ventilation is not adequate. (Mechanical ventilation does not improve pulmonary perfusion). The recommended position for clients who have one lung affected by a problem more than the other lung is to place the "good lung down," keeping the healthier lung dependent to the less healthy lung. Such positioning allows gravity to keep more blood in the lower lung (healthier lung) and better ventilation in the upper lung.
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A child has been diagnosed with Ewing sarcoma and is being started on a chemotherapy protocol. The mother questions the nurse on why more than one drug is being used as it would seem that using fewer drugs would decrease the side effects
The best response by the nurse would include the information that: 1. The child's cancer is a severe form and needs additional drugs to remove the cancer. 2. A protocol is a proven means of treatment. 3. A protocol is used in children but not adults due to the chemotherapy's effect on growth. 4. A protocol involves a group of drugs that work in different modes and have different side effects.
After interviewing a client for admission, the nurse gives the client a score of 50 on the Global Assessment of Functioning Scale (GAF). The nurse selected this score based on the client's level of functioning:
1. Since being given a psychiatric diagnosis. 2. Within the past week. 3. Since beginning the psychotropic medication. 4. Within the past year.
A nurse is being oriented to work for an intensive care unit. The hemodynamic data indicate that the patient has a decreased preload. Which information indicates the nurse has a correct under-standing of the concept of preload?
a. It is the amount of blood ejected from the left ventricle each minute. b. It is the amount of blood in the heart at the end of ventricular diastole. c. It is the resistance to the ejection of blood from the left ventricle. d. It is the rhythmic relaxation and contrac-tion of the heart chambers.
What are the two major types of euthanasia?
a. active and passive b. doctor-assisted and family-assisted c. inpatient and outpatient d. lethal injections and DNR orders