ECCO - Global Perspectives 2 Questions and Answers Graded A

ECCO - Global Perspectives 2 Questions and Answers Graded A A patient is recovering from moderate sedation with fentanyl (Sublimaze). The patient's BP is 30 mm Hg from baseline. Which should the nurse anticipate? Monitor vital signs every five minutes. Which intervention should the nurse employ first to prevent delirium and control pain in a patient on mechanical ventilation? Analgesic A patient with end-stage kidney disease (ESKD) managed with hemodialysis is hypotensive. The nephrologist agrees there are no options. The family agrees the patient is end of life. A DNR order is signed. Which has the highest priority? Explain to the family what to expect the patient's response and care to be as hemodialysis is discontinued. Upon extubation, a postoperative patient develops stridor, anxiety, and an inability to speak. Which intervention is initially indicated? Bag-valve mask ventilation In addition to clustering interventions to allow for uninterrupted sleep time, which strategy should the nurse use to help the patient receive adequate sleep? Use diurnal lighting (24-hour darkness/light pattern). Which interventions should the nurse anticipate to prevent delirium? Promote early mobility Which potential complications should the nurse monitor for in a patient receiving moderate sedation? Oversedation and hypoventilation In caring for a sedated post-procedure patient, what are the nurse's patient care priorities? -Record vital signs, sedation level, and oxygenation until patient is at pre-sedation LOC and function until the patient returns to pre-sedation state -Monitoring for pain and reorienting the patient as needed -Encourage the non-ventilated patient to take deep breaths. Which patient is demonstrating complete recovery from anesthesia? A patient: Able to deep breathe and having BP 20 mm Hg of baseline A patient is terminally ill and at end of life. The family asks for mechanical ventilation to be withdrawn. Once the provider writes the necessary orders, which intervention is indicated? Gradually withdraw support while managing symptoms In caring for a patient with a CVC, which intervention is indicated to help prevent CLABSI? Replace transparent dressing every seven days In caring for a patient who will undergo procedural sedation, what are the nurse's pre-procedure care priorities? -Perform team time-out to validate correct procedure and patient -Verify the type of procedure with patient and family, if possible -Mark procedure site for side or level. A patient is being seen by the palliative care team for management of dyspnea. SpO2 is 90% on room air. In addition to administration of low-dose opioids, which should the nurse anticipate? Performing guided imagery as needed Which action should the nurse implement prior to a patient undergoing a procedure with moderate sedation in order to ensure patient safety? The Universal Protocol In addition to using a closed suctioning system, which action will decrease the likelihood of VAE/VAP in patients? Change airway humidifiers every 5-7 days, as indicated. You are admitting a patient with sepsis who is intubated and on mechanical ventilation. Norephinephrine (Levophed) is being titrated based on MAP. Which are the patient's priority needs? -Ensuring patency of airway is maintained -Assessing hemodynamic status Which patient is at greatest risk for developing erosive gastritis? A patient who was placed on the ventilator the day prior and with INR 2 You admitted a patient with sepsis. In addition to unit protocols, what factor should the nurse consider about the frequency of reassessments? Degree of hemodynamic instability Which tool should the nurse use to assess a patient's quality and depth of sedation? Sedation-Agitation Scale (SAS) or Richmond Agitation-Sedation Scale (RASS) Which should the nurse employ to decrease a patient's risk of hospital-acquired pressure ulcers (HAPU)? Turn patient at a 30-degree angle with HOB elevated to 30 degrees. Turn patient at a 30-degree angle with HOB elevated to 30 degrees. What are the care priorities for a patient in the immediate postoperative period? -Maintaining airway and monitoring vital signs and recovery -Establish and maintain normothermia -Recognizing and intervening for complications. A patient is receiving morphine (Duramorph) and midazolam (Versed). The patient does not respond to verbal commands and has a CPOT score of 3 (out of 8). Which should the nurse anticipate? Increase the morphine rate You are caring for a patient undergoing a bedside colonoscopy under moderate sedation. The patient becomes agitated. Which action has the highest initial priority? Check the patient's SpO2 and vital signs Which intervention should the nurse implement to help prevent a CAUTI? Remove catheter if not indicated. A patient hospitalized with acute respiratory distress syndrome (ARDS) is now told he will be discharged soon. Which statements or actions may indicate PICS? Patient is unable to recall medication instructions he was taught yesterday.