An obstetric nurse comes across an automobile accident. The driver seems to have a crushed upper airway, and while waiting for emergency medical services to arrive, the nurse makes a cut in the trachea and inserts a straw from a purse to provide an airway. The patient survives and has a permanent problem with vocal cords, making it difficult to talk. Which statement is true regarding the nurse's performance?
The nurse stayed within the guidelines of the Good Samaritan Law.
The nurse acted appropriately and saved the patient's life.
The nurse should have just stayed with the patient and waited for help.
The nurse took actions beyond those that are standard and appropriate.
The Correct Answer is D
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.
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Correct Answer is A
Explanation
A. The P wave represents atrial depolarization, which is initiated by the SA node, the heart's natural pacemaker.
B. The AV node is responsible for conducting impulses from the atria to the ventricles but does not initiate the P wave.
C. The Bundle of His transmits the electrical impulses to the ventricles but is not directly associated with the P wave.
D. Purkinje fibers are involved in ventricular depolarization, which corresponds to the QRS complex, not the P wave.
Correct Answer is D
Explanation
A. Vision is not commonly affected by vancomycin, so it is not a priority to assess.
B. Heart tones are not directly impacted by vancomycin and do not require immediate monitoring unless there are specific cardiovascular concerns.
C. Bowel sounds are not directly influenced by vancomycin and do not need to be prioritized in this case.
D. Vancomycin is known to be ototoxic, especially in high doses or with prolonged use, so monitoring for signs of hearing loss or tinnitus is essential to prevent potential irreversible damage.