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. The insertion of a pulmonary artery catheter can help in assessing hemodynamic parameters and distinguishing between these two conditions. It provides direct measurement of pulmonary artery pressures, which can be elevated in the case of heart failure.

B. A ventilation-perfusion (V/Q) scan is used to evaluate ventilation and perfusion in the lungs. While it can help identify areas of ventilation-perfusion mismatch, it may not be the most appropriate initial test for distinguishing between ARDS and pulmonary edema.

C. Drawing blood for arterial blood gases is also a critical step as it helps in assessing the severity of hypoxemia and respiratory failure.

D. A chest x-ray can show the presence of bilateral opacities, which are indicative of ARDS when cardiac failure or fluid overload is not the primary cause. However, transthoracic echocardiography (TTE) is often performed to seek evidence of cardiac dysfunction when cardiogenic pulmonary edema cannot be excluded by clinical evaluation, laboratory findings, or imaging.

A. Bradycardia. B. Muffled heart sounds C. Flattened neck veins. D. Sudden lethargy.

Correct Answer is B

Explanation

B. Muffled heart sounds, often described as distant or indistinct, are classic findings in cardiac tamponade. The accumulation of fluid in the pericardial sac dampens the transmission of sound from the heart to the chest wall, resulting in muffled heart sounds on auscultation. This finding is known as Beck's triad, which also includes hypotension and jugular venous distention.

A. Bradycardia is not a typical finding in cardiac tamponade. In fact, tachycardia is more commonly observed due to the compensatory response to decreased cardiac output and decreased stroke volume. The sympathetic nervous system is activated, leading to an increase in heart rate as a compensatory mechanism to maintain cardiac output.

C. Flattened neck veins are not consistent with cardiac tamponade. In cardiac tamponade, jugular venous distention (JVD) is typically observed due to increased venous pressure resulting from impaired right ventricular filling. The presence of JVD is an important clinical finding in cardiac tamponade and can help differentiate it from other causes of shock.

D. Sudden lethargy can occur in various medical emergencies, including cardiac tamponade, but it is not a specific or diagnostic finding for this condition. In cardiac tamponade, symptoms may include dyspnea, chest pain, hypotension, and signs of decreased cardiac output such as cool extremities and altered mental status. However, sudden lethargy alone may not be specific enough to confirm cardiac tamponade.

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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 patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. What procedure should the nurse anticipate assisting with to determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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