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 C

Explanation

C. Mean arterial pressure (MAP) reflects the average pressure in the arteries during one cardiac cycle and is an important indicator of tissue perfusion. A MAP of 56 mm Hg is below the normal range (typically >60 mm Hg) and may indicate inadequate tissue perfusion. While norepinephrine is commonly used to increase blood pressure and improve tissue perfusion in hypotensive patients, a MAP of 56 mm Hg suggests that the current infusion rate may not be sufficient to maintain adequate perfusion, and adjusting the infusion rate may be warranted.

A. Norepinephrine is a vasopressor medication primarily used to increase blood pressure in patients with hypotension or shock. A low pulmonary artery wedge pressure (PAWP) suggests decreased preload, which may indicate hypovolemia or inadequate fluid resuscitation. In this case, adjusting the norepinephrine infusion rate may not be necessary, but rather addressing the underlying cause of hypovolemia or inadequate preload.

B. Systemic vascular resistance (SVR) represents the resistance the heart must overcome to pump blood into the systemic circulation. An elevated SVR may suggest vasoconstriction, which could be a desired effect of norepinephrine infusion to increase blood pressure. Therefore, an elevated SVR may not necessarily indicate a need to adjust the norepinephrine infusion rate, as it may reflect the medication's intended action.

D. Norepinephrine primarily acts on alpha-adrenergic receptors to increase blood pressure by inducing vasoconstriction. While it may cause reflex bradycardia due to increased systemic vascular resistance, a heart rate of 58 beats/min may be within an acceptable range depending on the patient's clinical condition and baseline heart rate. Therefore, a slow heart rate alone may not necessarily indicate a need to adjust the norepinephrine infusion rate unless it is associated with signs of inadequate tissue perfusion or other concerning symptoms.

A. Irregular B. Bounding C. Not palpable D. Slow

Correct Answer is A

Explanation

A In atrial fibrillation (AF), the electrical activity in the atria is chaotic, leading to an irregularly irregular ventricular response. As a result, the pulse felt at the radial artery will be irregular, with no discernible pattern. The irregularity is a hallmark feature of AF and is often described as "irregularly irregular."

B Bounding pulses are characterized by a strong and forceful pulsation felt at the arterial pulse sites. In atrial fibrillation, the irregular and rapid ventricular response can lead to an increased stroke volume and forceful contraction of the left ventricle during diastole, resulting in bounding pulses. However, bounding pulses are not typically associated with atrial fibrillation; they are more commonly seen in conditions such as aortic regurgitation or hyperdynamic circulation.

C In some cases of atrial fibrillation, especially if the ventricular rate is very rapid or irregularly irregular, the pulse may not be palpable due to the inconsistent ventricular contractions.

However, in most cases of atrial fibrillation, a pulse is palpable, albeit irregular.

D Atrial fibrillation can result in a rapid ventricular response, leading to a fast heart rate. However, the pulse rate can vary widely among individuals with atrial fibrillation. While some may have a rapid heart rate (tachycardia), others may have a slower heart rate (bradycardia), depending on factors such as concomitant medications, autonomic tone, and the presence of underlying heart disease.

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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

The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which finding indicates that the infusion rate may need to be adjusted?

Correct Answer is C

Explanation

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

Correct Answer is A

Explanation

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