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whatsupgirl whatsupgirl
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Posts: 340
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6 years ago
A patient was admitted to the critical care unit with acute respiratory failure
 
  The patient has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure alarm keeps going off. When you enter the room, the ventilator inoperative alarm sounds. What is the primary action the nurse would take?
 
  a. Troubleshoot the ventilator until the problem is found.
  b. Take the patient off the ventilator and manually ventilate her.
  c. Call the respiratory therapist for help.
  d. Silence the ventilator alarms until the problem is resolved.

Question 2

A patient is admitted to the critical care unit in congestive heart failure secondary to renal insufficiency.
 
  The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The patient weight upon admission was 176 lb. The patient's weight the next day is 184 lb. What is the approximate amount of fluid retained with this weight gain?
 
  a. 800 mL
  b. 2200 mL
  c. 3600 mL
  d. 8000 mL

Question 3

Which of the following cardiac enzymes is a highly specific biomarker for myocardial damage?
 
  a. CK-MB
  b. Troponin I
  c. Troponin T
  d. LDH

Question 4

Which of the following assessment findings would indicate fluid volume excess?
 
  a. Venous filling of the hand veins greater than 5 seconds
  b. Distended neck veins in the supine position
  c. Presence of orthostatic hypotension
  d. Third heart sound
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Replies
wrote...
6 years ago
The answer to question 1

B
Ensure emergency equipment is at bedside at all times (e.g., manual resuscitation bag connected to oxygen, masks, suction equipment or supplies), including preparations for power failures. If the ventilator malfunctions, the patient should be removed from the ventilator and ventilated manually with a manual resuscitation bag.

The answer to question 2

C
One liter of fluid equals 1 kg, which is 2.2 pounds; 8 pounds equals 3.6 kg, which is 3.6 liters; 3.6 liters is equal to 3600 mL.

The answer to question 3

B
Because cTnI is found only in cardiac muscle, it is a highly specific biomarker for myocardial damage, considerably more specific than CK-MB. As a consequence, patients with a positive cTnI result and a negative CK-MB result usually rule in an acute myocardial infarction (MI). A negative cTnI result that remains negative many hours after an episode of chest pain is a strong indicator that the patient is not experiencing an acute MI. Even with a negative cTnI result, symptoms of chest pain still indicate that the patient should have a comprehensive cardiac evaluation to determine if there is underlying CAD present that may later lead to complications.

The answer to question 4

D
Auscultation of the heart requires not only assessing rate and rhythm but also listening for extra sounds. Fluid overload is often accompanied by a third or fourth heart sound, which is best heard with the bell of the stethoscope.
whatsupgirl Author
wrote...
6 years ago
You are really a genius. Thanks
wrote...
6 years ago
NP
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