A male patient informs the nurse that he prefers not to have female assistive personnel (AP) involved in his care. Which response should the nurse provide?

“I can arrange for a male AP to assist with your personal hygiene care.”

“Could you explain why you prefer not to have a female AP assigned to your care?”

“The AP assigned to you is highly competent and has experience caring for male patients.”

“I will inform the charge nurse about your request to have only male staff members assigned to your care.”

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Respects patient autonomy: This response directly addresses the patient's preference and demonstrates respect for their right to make decisions about their own care. It empowers the patient by offering a solution that aligns with their stated wishes.

Promotes patient comfort: By accommodating the patient's preference, the nurse can help to create a more comfortable and trusting environment, which can lead to better patient outcomes.

Protects patient privacy: Personal hygiene care often involves exposure of sensitive body parts and can be a source of embarrassment or anxiety for some patients. Ensuring that the patient is comfortable with the gender of the caregiver helps to protect their privacy and dignity.

Demonstrates cultural sensitivity: While not explicitly stated in the question, it's possible that the patient's preference is rooted in cultural or religious beliefs. Being sensitive to these factors is essential for providing culturally competent care.

Provides a practical solution: This response offers a concrete solution that can be easily implemented, ensuring that the patient's needs are met in a timely and efficient manner.

Choice B rationale:

May be perceived as intrusive: Asking the patient to explain their reasoning could make them feel uncomfortable or defensive. It's important to respect the patient's right to privacy and not pressure them to disclose personal information.

Could delay care: While understanding the patient's reasons may be helpful in some cases, it's not essential for providing appropriate care. Delaying care to gather this information could potentially compromise the patient's well-being.

Choice C rationale:

Dismisses patient's concerns: This response fails to acknowledge the patient's preference and could make them feel unheard or disrespected. It's important to validate the patient's feelings and concerns, even if you don't fully understand them.

May not address underlying issues: The patient's preference may be based on factors that are not related to the AP's competence or experience. Simply stating the AP's qualifications is unlikely to resolve the patient's concerns.

Choice D rationale:

Defers responsibility: While informing the charge nurse may be necessary for logistical reasons, it's important for the nurse to take ownership of the situation and address the patient's concerns directly. Deferring to another staff member could make the patient feel like their concerns are not being taken seriously.

May delay care: Involving additional staff members could potentially delay the patient's care. It's more efficient to address the patient's preference directly, if possible.

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Correct Answer is ["A","B","E","F"]

Explanation

Choice A rationale:

Temperature control for either hypothermia or hyperthermia is crucial in septic shock management. Here's a detailed explanation:

Hypothermia:

Mechanism: Septic shock often causes impaired thermoregulation, leading to hypothermia. It can worsen shock by decreasing cardiac output, impairing coagulation, and promoting vasoconstriction.

Intervention: Active warming measures are essential, including: External warming devices (e.g., blankets, forced air warmers) Intravenous fluids warmed to 39-42°C

Warmed humidified oxygen

Minimizing exposure and covering the patient Hyperthermia:

Mechanism: Sepsis can trigger an excessive inflammatory response, leading to hyperthermia. It can exacerbate tissue injury, increase metabolic demands, and worsen organ dysfunction.

Intervention: Aggressive measures to lower temperature are necessary, including:

Antipyretic medications (e.g., acetaminophen, ibuprofen) External cooling methods (e.g., cooling blankets, ice packs) Sedation if shivering occurs

Choice B rationale:

Administration of cardiotonic agents such as dopamine, dobutamine, or norepinephrine is often required in septic shock to: Improve cardiac output: These agents increase myocardial contractility and heart rate, enhancing blood flow to vital organs.

Maintain blood pressure: They support vasoconstriction, counteracting the widespread vasodilation characteristic of septic shock.

Improve tissue perfusion: By optimizing cardiac output and blood pressure, they help ensure adequate oxygen and nutrient delivery to tissues.

Choice E rationale:

Blood cultures from all suspected sources before administration of antibiotics are essential for guiding appropriate antibiotic therapy.

Early identification of the causative organism: This information is crucial for selecting the most effective antibiotic regimen.

Prevention of antibiotic resistance: Judicious use of antibiotics based on culture results helps prevent the development of antibiotic-resistant bacteria.

Choice F rationale:

Vigorous intravenous fluid resuscitation with 0.9% sodium chloride is a cornerstone of septic shock management.

Replenishing intravascular volume: Septic shock often causes profound intravascular volume depletion due to capillary leak and vasodilation. Fluid resuscitation aims to restore circulating volume and maintain organ perfusion.

Improving hemodynamic stability: By increasing preload and cardiac output, fluids help stabilize blood pressure and support vital organ function.

A. Metabolic alkalosis. B. Metabolic acidosis. C. Respiratory alkalosis. D. Respiratory acidosis.

Correct Answer is B

Explanation

Choice A rationale:

Metabolic alkalosis is characterized by a high pH (above 7.45), high bicarbonate (HCO3-) levels, and normal or low PaCO2. The patient's ABGs show a low pH (7.26), low bicarbonate (14 mEq/L), and low PaCO2 (30 mm Hg), which are not consistent with metabolic alkalosis.

Choice C rationale:

Respiratory alkalosis is characterized by a high pH (above 7.45), low PaCO2, and normal or slightly elevated bicarbonate levels. The patient's ABGs do show a low PaCO2, but the pH is low (acidic) and the bicarbonate is low, which are not consistent with respiratory alkalosis.

Choice D rationale:

Respiratory acidosis is characterized by a low pH (below 7.35), high PaCO2, and normal or slightly elevated bicarbonate levels. The patient's ABGs do show a low pH, but the PaCO2 is also low, which is not consistent with respiratory acidosis.

Rationale for the correct answer, B:

Metabolic acidosis is characterized by a low pH (below 7.35), low bicarbonate levels, and normal or low PaCO2. The patient's ABGs are consistent with metabolic acidosis because they show a low pH (7.26), low bicarbonate (14 mEq/L), and low PaCO2 (30 mm Hg).

Acute kidney injury is a common cause of metabolic acidosis. The kidneys play a vital role in regulating acid-base balance by excreting acids and reabsorbing bicarbonate. When the kidneys are damaged, they are unable to excrete acids effectively, leading to an accumulation of acids in the blood and a decrease in bicarbonate levels.

Additional Information:

It's important to note that the patient's low PaCO2 is likely a compensatory mechanism for the metabolic acidosis. In response to acidosis, the respiratory system tries to increase ventilation to blow off more carbon dioxide, which helps to raise the pH. However, this compensatory mechanism is often not enough to fully correct the acidosis.

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A male patient informs the nurse that he prefers not to have female assistive personnel (AP) involved in his care. Which response should the nurse provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has been diagnosed with septic shock.What collaborative interventions would be expected? (Select all that apply)

Correct Answer is ["A","B","E","F"]

Explanation

A nurse is caring for a patient who has acute kidney injury.The patient’s ABGs are: pH: 7.26, PaCO2: 30 mm Hg, HCO3: 14 mEq/L. Which of the following acid-base imbalances should the nurse identify the patient is experiencing?

Correct Answer is B

Explanation

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