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. Pacemaker spikes before each QRS complex: This is the correct answer. In a client with a ventricular pacemaker, the pacemaker spikes should precede each QRS complex on the ECG strip. This indicates that the pacemaker is appropriately stimulating the ventricles to depolarize and initiate a heartbeat. The

presence of pacemaker spikes before each QRS complex signifies that the pacemaker is functioning properly and effectively pacing the ventricles.

B. Pacemaker spikes occurring after each QRS complex would suggest a malfunction or inappropriate timing of the pacemaker. In this scenario, the pacemaker would not be pacing the ventricles as intended. This would be an abnormal finding and would require further assessment and intervention.

C. Pacemaker spikes preceding each P wave would suggest pacing of the atria rather than the ventricles. This would indicate a different type of pacemaker (atrial pacemaker) or inappropriate pacing settings for a ventricular pacemaker. In either case, it would be considered abnormal for a ventricular pacemaker and would require evaluation and possibly reprogramming of the pacemaker.

D. Pacemaker spikes occurring with each T wave would be an abnormal finding and would suggest interference or oversensing by the pacemaker. This could lead to inappropriate pacing or dysrhythmias. It would require further investigation and correction to ensure proper pacemaker function.

A. Intracranial pressure B. Renal function C. Spinal cord perfusion D. Hemodynamic status

Correct Answer is D

Explanation

D. A pulmonary artery catheter is used to monitor hemodynamic status. It provides valuable information about cardiac function, preload, afterload, and cardiac output. By measuring parameters such as pulmonary artery pressure, pulmonary artery wedge pressure, and central venous pressure, a pulmonary artery catheter helps assess the effectiveness of cardiac function and guide management in critically ill patients, especially those with conditions such as heart failure, shock, or pulmonary hypertension.

A. A pulmonary artery catheter, also known as a Swan-Ganz catheter, is not used to monitor intracranial pressure. Instead, it is primarily used to assess hemodynamic status and cardiac function by measuring parameters such as pulmonary artery pressure, pulmonary artery wedge pressure, central venous pressure, and cardiac output.

B. A pulmonary artery catheter is not used to directly monitor renal function. While changes in hemodynamic status can impact renal perfusion and function, the primary purpose of a pulmonary artery catheter is to assess cardiac function and hemodynamics, rather than renal function.

C. A pulmonary artery catheter is not used to monitor spinal cord perfusion. Although alterations in hemodynamic status can affect spinal cord perfusion indirectly, the main purpose of a pulmonary artery catheter is to evaluate cardiac function and hemodynamics.

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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

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?

Correct Answer is A

Explanation

A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?

Correct Answer is D

Explanation

Which is(are) potential result(s) of end-organ damage from chronic hypertension? (Select all that apply.)

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A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)

A client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse should explain to the client that a murmur

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