An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. What should the nurse plan to do?

Give PRN lorazepam (Ativan) and cancel the transfer.

Obtain an order for restraints as needed and transfer the patient.

Notify the health care provider and postpone the transfer.

Inform the receiving nurse and then transfer the patient.

Answer and Explanation

The Correct Answer is C

C. This allows for the patient's condition to be re-evaluated, ensuring that they receive the necessary care and attention before being transferred.

A. Benzodiazepines can cause sedation, cognitive impairment, and delirium, which may worsen the patient's condition. Canceling the transfer without addressing the underlying cause of confusion may delay appropriate management.

B. Restraints can increase agitation, anxiety, and risk of injury, and they do not address the underlying cause of confusion. Restraints should only be considered as a last resort if all other measures to ensure patient safety have been exhausted.

D. This option is not appropriate because transferring the patient without addressing the new-onset confusion could compromise patient safety. It's essential to identify and manage the underlying cause of confusion before transferring the patient to another unit.

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Correct Answer is A

Explanation

A. Positive end-expiratory pressure (PEEP) is applied during mechanical ventilation to prevent alveolar collapse at the end of expiration. It helps maintain the patency of the alveoli, improving oxygenation and preventing atelectasis.
B. While PEEP can improve oxygenation by recruiting collapsed alveoli and increasing functional residual capacity, it does not directly affect the concentration of oxygen delivered by the ventilator. Oxygen concentration is adjusted separately from PEEP settings.
C. PEEP is applied at the end of expiration to maintain positive pressure in the airways and alveoli, preventing them from collapsing. It does not directly affect the delivery of air during inhalation.
D. PEEP can help prevent lung damage by maintaining alveolar recruitment and reducing the risk of atelectasis and barotrauma. However, it is not the sole factor in preventing lung damage, and other ventilator settings and strategies also play a role in protecting the lungs.

A. Administer the prescribed daily dose of metoprolol B. Obtain the client's blood pressure and pulse C. Notify the health care provider about the rhythm D. Print a rhythm strip to document the changes in the health record

Correct Answer is B

Explanation

B. Assessing the client's vital signs, including blood pressure and pulse, provides critical information about the client's hemodynamic status and response to the new rhythm. Atrial fibrillation can lead to rapid, irregular heart rates and hemodynamic instability, so obtaining vital signs promptly helps the nurse determine the severity of the situation and whether immediate intervention is needed.

A. This action is not the priority when the nurse observes a new onset of atrial fibrillation. While beta- blockers such as metoprolol may be part of the client's long-term management for heart failure and atrial fibrillation, initiating medication administration without further assessment could delay appropriate intervention for the acute change in rhythm.

C. While it is important to communicate changes in the client's condition to the healthcare provider, this action should occur after the nurse has assessed the client's vital signs and determined the urgency of the situation. If the client is stable and responsive to initial interventions, the nurse can then contact the healthcare provider to discuss the new onset of atrial fibrillation and collaborate on further management.

D. Documenting the changes in the client's rhythm is important for continuity of care and communication among healthcare team members. However, obtaining a rhythm strip should not be the first action when a new onset of atrial fibrillation is observed. Assessing the client's vital signs and initiating appropriate interventions to address any hemodynamic instability take precedence.

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An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. What should the nurse plan to do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate?

Correct Answer is A

Explanation

The nurse is caring for a client with a history of heart failure and notes a new onset of the following rhythm on the client's telemetry monitor. Which action would the nurse take first?

Correct Answer is B

Explanation

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A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

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