A Muslim woman is admitted to the ICU after suffering severe burns over most of her body. Which of the following would be the most appropriate measure for the nurse, a woman, to take in respect for the cultural practices of this patient?

Correct Answer: D

Rationale: The correct answer is D because it demonstrates respect for the patient's autonomy and individual preferences. By asking the patient's husband about religious and cultural preferences, the nurse acknowledges the importance of involving the family in decision-making and shows sensitivity to the patient's beliefs. This approach promotes cultural competence and patient-centered care. Choice A is incorrect because insisting on a female doctor may not align with the patient's preferences and may limit the available medical staff. Choice B is also incorrect as dietary restrictions are not necessarily the most pressing issue in this scenario. Choice C is incorrect as it assumes a cultural practice without verifying the patient's specific preferences and may not be necessary or appropriate in this context.

Correct Answer: C

Rationale: The correct answer is C: Insertion of a vena cava filter. This is a strategy for preventing thromboembolism in patients at risk who cannot take anticoagulants. The vena cava filter prevents blood clots from traveling to the lungs by trapping them in the inferior vena cava. It is a mechanical device that does not interfere with the body's clotting process. Explanation of why other choices are incorrect: A: Administration of two aspirin tablets every 4 hours is not an effective strategy for preventing thromboembolism in high-risk patients. Aspirin is an antiplatelet agent and may not be sufficient for preventing blood clots in these patients. B: Infusion of thrombolytics is used for breaking down blood clots that have already formed, not for prevention. It is not a suitable option for preventing thromboembolism in at-risk patients. D: Subcutaneous heparin administration every 12

Correct Answer: D

Rationale: The correct answer is D because using an end-tidal CO2 monitor is the most reliable method to confirm correct endotracheal tube placement in the trachea. This method detects exhaled CO2, indicating proper tube placement in the trachea. It is a quick and efficient way to confirm placement without delay, reducing the risk of complications. A: Auscultating for bilateral breath sounds is not as reliable because breath sounds may be heard even if the tube is misplaced. B: Obtaining a portable chest x-ray is not the best initial action as it takes time and delays confirming tube placement. C: Observing chest movement may not provide conclusive evidence of proper tube placement and can lead to misinterpretation. In summary, using an end-tidal CO2 monitor is the most accurate and efficient method to verify correct endotracheal tube placement compared to the other options.

Correct Answer: C

Rationale: The correct answer is C: Pressure support ventilation. This mode delivers a set pressure to support each spontaneous breath, decreasing the workload of breathing. Pressure support ventilation assists the patient's inspiratory efforts without providing a set tidal volume like in volume-targeted ventilation. Continuous positive airway pressure (Choice A) maintains a constant level of positive pressure throughout the respiratory cycle but does not actively support spontaneous breathing efforts. Positive end-expiratory pressure (Choice B) maintains positive pressure at the end of expiration to prevent alveolar collapse but does not directly support spontaneous breathing. T-piece adapter (Choice D) is a weaning device that allows the patient to breathe spontaneously without ventilatory support.

Correct Answer: A

Rationale: The correct answer is A because implementing more aggressive wound care strategies is essential for managing pressure ulcers effectively. This includes proper wound cleaning, debridement, and dressing changes to promote healing. Adequate hydration and nutrition (choice B) are important but may not directly address the pressure ulcer. Discussing prognosis and expected outcomes (choice C) is important but may not directly impact wound healing. Encouraging increased physical activity (choice D) may be contraindicated due to the patient's condition.

Correct Answer: A

Rationale: The correct answer is A: Review daily the necessity of the central venous catheter. This action reduces the risk of CRBSI by promoting early removal of unnecessary catheters, which is a key strategy in preventing infections. Unnecessary catheters increase the risk of infection due to prolonged exposure to the patient's skin flora and possible contamination during insertion. Reviewing daily ensures the catheter is only kept when necessary, minimizing the duration of catheter use and reducing the chances of infection. Summary of other choices: B: Cleansing the insertion site daily with isopropyl alcohol is important for maintaining skin integrity but does not directly reduce the risk of CRBSI. C: Changing the pressurized tubing system and flush bag daily is important for maintaining catheter patency but does not directly reduce the risk of CRBSI. D: Maintaining a pressure of 300 mm Hg on the flush bag is important for proper catheter function but does not directly reduce the risk of CR

Correct Answer: C

Rationale: Rationale: Choice C is correct because a surrogate is indeed a competent adult designated to make healthcare decisions for an incapacitated person. This individual is typically chosen by the person themselves through a legal document like a healthcare proxy. This ensures that someone trusted can make important decisions when the person is unable to do so. Choices A, B, and D are incorrect because a living will and healthcare proxy serve different purposes, a signed donor card does not guarantee organ donation in the event of brain death (medical criteria are also required), and a persistent vegetative state is different from brain death (brain death implies irreversible cessation of brain function while a vegetative state involves some level of brain function).

Correct Answer: B

Rationale: The correct answer is B: Increase the IV fluid infusion per protocol. Low CVP post-abdominal aortic aneurysm surgery could indicate hypovolemia, which requires fluid resuscitation. Increasing IV fluid infusion helps restore intravascular volume, improve tissue perfusion, and prevent hypotension. Administering diuretics (A) would worsen hypovolemia. Documenting (C) is important but not the priority when the patient needs immediate intervention. Elevating the head of the bed (D) may help with venous return but is not the priority over addressing hypovolemia.

Correct Answer: D

Rationale: The correct answer is D because it demonstrates respect for the patient's autonomy and individual preferences. By asking the patient's husband about religious and cultural preferences, the nurse acknowledges the importance of involving the family in decision-making and shows sensitivity to the patient's beliefs. This approach promotes cultural competence and patient-centered care. Choice A is incorrect because insisting on a female doctor may not align with the patient's preferences and may limit the available medical staff. Choice B is also incorrect as dietary restrictions are not necessarily the most pressing issue in this scenario. Choice C is incorrect as it assumes a cultural practice without verifying the patient's specific preferences and may not be necessary or appropriate in this context.