Correct Answer: D

Rationale: The correct answer is D because the client's medical chart is the property of the hospital, but the client has the right to a copy of the information. By offering to make a copy of the chart for the client, the nurse respects the client's autonomy while also ensuring that the hospital maintains the original medical record. This response balances the client's rights with legal and ethical considerations. Choice A is incorrect because the hospital is legally obligated to maintain the client's medical record even if the client leaves against medical advice. Choice B is incorrect as it denies the client access to their medical information, which goes against the principle of patient autonomy. Choice C is also incorrect as it does not address the client's request for a copy of their chart.

Correct Answer: B

Rationale: The correct answer is B: Assess the patient’s lungs. Rhabdomyolysis can lead to acute kidney injury due to myoglobin release from damaged muscle cells. IV fluids and mannitol are given to prevent kidney damage by promoting myoglobin excretion. Assessing the patient’s lungs is crucial to monitor for potential complications such as acute respiratory distress syndrome (ARDS) which can occur as a result of rhabdomyolysis. This assessment helps to ensure early detection and prompt intervention if respiratory issues arise. Summary of Incorrect Choices: A: Assess the patient’s hearing - This is not directly related to rhabdomyolysis or its treatment. C: Decrease IV fluids once the diuretic has been administered - Decreasing IV fluids can exacerbate kidney injury in rhabdomyolysis. D: Give extra doses before giving radiological contrast agents - Mannitol is not routinely given before radiological contrast agents in the context of rhabdomyolysis management.

Correct Answer: B

Rationale: The correct answer is B: Administration of morphine, 5 mg IV bolus, and initiation of a continuous morphine infusion. Morphine is the preferred pharmacological management for severe dyspnea in end-stage heart failure due to its potent analgesic and anxiolytic properties. Step-by-step rationale: 1. Morphine is a potent opioid that helps relieve dyspnea by reducing anxiety, decreasing respiratory drive, and improving overall comfort. 2. The initial IV bolus of 5 mg provides rapid relief of dyspnea. 3. Initiating a continuous morphine infusion ensures sustained relief of dyspnea. 4. Midazolam (choice A) is a benzodiazepine used for sedation and anxiety, but it is not the first-line treatment for dyspnea in this scenario. 5. Increasing the midazolam (choice C) or morphine (choice D) infusions by 100% dose increments hourly is not appropriate as

Correct Answer: C

Rationale: The correct answer is C: Neuromuscular blockade. 1. Neuromuscular blockade helps to achieve optimal ventilator synchrony by reducing patient-ventilator asynchrony and improving oxygenation in patients with acute respiratory distress syndrome (ARDS). 2. Despite sedation, the patient's restlessness and discomfort suggest inadequate ventilator synchrony, which can be addressed by neuromuscular blockade. 3. Continuous lateral rotation therapy (A) and prone positioning (D) are interventions for improving ventilation and oxygenation in ARDS but do not directly address patient-ventilator synchrony. 4. Guided imagery (B) is a non-pharmacological technique for relaxation and pain management, which may not address the underlying issue of ventilator synchrony in this case.

Correct Answer: A

Rationale: The correct answer is A: Question the type and quantity of foods eaten in a typical day. When a child's weight is in the 95th percentile for their height, it indicates possible overweight or obesity. To address this, the nurse should assess the child's dietary habits to identify any unhealthy eating patterns contributing to excess weight. By questioning the type and quantity of foods eaten, the nurse can provide appropriate guidance on nutrition and healthy eating habits. Summary: B: Encouraging additional snacks may further contribute to weight gain and is not recommended without knowing the current eating habits. C: Recommending a high intake of whole milk may increase calorie intake and potentially worsen the weight concern. D: Assessing for signs of poor nutrition, such as a pale appearance, is important but not directly addressing the weight concern in this scenario.