After change-of-shift report, which patient should the ...

[jrubin]

After change-of-shift report, which patient should the progressive care nurse assess first?
 
  a. Patient who was extubated in the morning and has a temperature of 101.4 F (38.6 C)
  b. Patient with bilevel positive airway pressure (BiPAP) for sleep apnea whose respiratory rate is 16
  c. Patient with arterial pressure monitoring who is 2 hours postpercutaneous coronary intervention who needs to void
  d. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 98 sec

Question 2

After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first?
 
  a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator
  b. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring
  c. Patient with a central venous oxygen saturation (ScvO2) of 69 while on bilevel positive airway pressure (BiPAP)
  d. Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours

[kswal303]

Answer to Question 1

ANS: D
The findings for this patient indicate high risk for bleeding from an elevated (nontherapeutic) PTT. The nurse needs to adjust the rate of the infusion (dose) per the health care provider's parameters. The patient with BiPAP for sleep apnea has a normal respiratory rate. The patient recovering from the percutaneous coronary intervention will need to be assisted with voiding and this task could be delegated to unlicensed assistive personnel. The patient with a fever may be developing ventilator-associated pneumonia, but addressing the bleeding risk is a higher priority.

Answer to Question 2

ANS: D
The decreased urine output may indicate acute kidney injury or that the patient's cardiac output and perfusion of vital organs have decreased. Any of these causes would require rapid action. The data about the other patients indicate that their conditions are stable and do not require immediate assessment or changes in their care. Continuous PETCO2 monitoring is frequently used when patients are intubated. The rest mode should be used to allow patient recovery after a failed SBT, and an ScvO2 of 69 is within normal limits.

[jrubin]

Thank you

[kswal303]

No problemo