A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation?
Anxiety over illness
Increased metabolic demands
Decreased drive to breathe
Infection destroying lung tissues
The Correct Answer is B
A. While anxiety may contribute to hyperventilation, in the context of a febrile child, the primary factor is usually metabolic.
B. Increased metabolic demands due to fever can elevate the body’s oxygen requirements, prompting hyperventilation as a compensatory mechanism.
C. Decreased drive to breathe would not lead to hyperventilation; rather, it might result in hypoventilation or respiratory distress.
D. Infection destroying lung tissues would typically lead to respiratory distress or failure, not directly cause hyperventilation without the context of increased metabolic needs.
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Correct Answer is C
Explanation
A. Competent nurses have typically worked in a specific area for 2-3 years, developing an understanding of patient care specific to that field.
B. Proficient nurses have advanced understanding and experience, allowing them to see care situations as whole parts rather than in separate steps.
C. In a new specialty area, the nurse is considered a novice, as they lack experience and expertise in obstetrics despite previous nursing experience.
D. Advanced beginners have some experience but still need support; however, this would apply only if the nurse had some previous obstetric experience.
Correct Answer is D
Explanation
A. The Good Samaritan Law typically protects individuals who provide care in emergency situations but may not apply if the actions taken are beyond the standard of care or are not in the nurse's training.
B. While the nurse's intention was to save the patient's life, the method employed was not a recognized standard procedure for airway management and may have caused harm.
C. Waiting for help may not have been an appropriate option if the patient's airway was compromised, but the method employed by the nurse was not advisable.
D. Cutting into the trachea and using a straw as a makeshift airway are actions that exceed the typical scope of nursing practice and could be deemed inappropriate, regardless of the outcome for the patient.