A nurse is caring for a client receiving IV moderate sedation with midazolam. The client has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse?

Correct Answer: B

Rationale: The correct answer is B: Implement positive pressure ventilation. This action is appropriate because the client's respiratory rate of 9/min indicates hypoventilation, which can lead to hypoxemia and respiratory arrest. Positive pressure ventilation helps support adequate oxygenation and ventilation. Placing the client in a prone position (choice A) can further compromise breathing. Nasopharyngeal suctioning (choice C) is not indicated unless airway obstruction is confirmed. Administering flumazenil (choice D) is contraindicated in clients with significant respiratory depression due to the risk of precipitating seizures.

Correct Answer: A

Rationale: The correct answer is A: research/client preference/nurse competency. Evidence-based practice involves integrating the best available research evidence with a patient's preferences and the nurse's clinical expertise. Research ensures interventions are based on proven effectiveness. Client preference acknowledges the importance of individual needs and values. Nurse competency ensures that care is delivered skillfully. Choice B (nurse experience/collaboration/teamwork) lacks the essential component of research evidence, which is crucial for evidence-based practice. While collaboration and teamwork are important, they do not encompass all three components. Choice C (research/client safety/client preference) includes client safety, which is essential but does not cover nurse competency, a key component of evidence-based practice. Choice D (nurse experience/client teaching/delegation) misses the mark by not including research evidence and client preference, which are integral to evidence-based practice. Delegation and client teaching are important but not part of the core components.

Correct Answer: A

Rationale: The correct answer is A because prohibiting a patient from using the telephone violates their right to communication. Patients have the right to contact others for support or assistance. Choice B is incorrect because opening a package in the patient's presence is not a violation of their rights. Choice C is incorrect because maintaining close supervision of a patient with homicidal ideation is necessary for safety. Choice D is incorrect because allowing a patient with psychosis to refuse medication respects their autonomy and right to make informed decisions about their treatment.

Correct Answer: D

Rationale: The correct answer is D: Schizophrenia and alcohol abuse. This combination is appropriate for a dual-diagnosis group because it involves both a severe mental illness (schizophrenia) and a substance abuse issue (alcohol abuse). Patients with schizophrenia often have co-occurring substance abuse disorders, making them suitable for a dual-diagnosis group to address both issues simultaneously. This group can provide comprehensive treatment and support for individuals struggling with complex mental health and substance abuse issues. Choices A, B, and C are incorrect because they do not involve the combination of a severe mental illness and a substance abuse issue, which is essential for a dual-diagnosis group. Choice A (Depression and suicidal tendencies) may benefit from a different type of group focused on mood disorders and suicide prevention. Choice B (Anxiety and frequent migraine headaches) may require a group focused on stress management and pain coping strategies. Choice C (Bipolar disorder and anorexia nervosa) may benefit from a group addressing

Correct Answer: B

Rationale: The correct answer is B: Identifying a clinical question. This is the first step in implementing evidence-based practice because it helps focus the research efforts on a specific issue or problem. By identifying a clinical question, the nurse can then conduct research to gather evidence that will guide decision-making. The other choices are incorrect: A: Conducting research - While conducting research is an essential part of evidence-based practice, it comes after identifying a clinical question. C: Determining outcomes - Determining outcomes is crucial for evaluating the effectiveness of interventions, but it is not the first step in developing evidence-based practice. D: Collaborating with the patient - Collaborating with the patient is important in providing individualized care, but it is not the initial step in implementing evidence-based practice.