A nurse is monitoring a client after moderate sedation. The nurse documents the clients Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: A

Rationale: A small flail chest injury, where a segment of ribs is fractured in multiple places, disrupts chest wall stability but, if minor, is managed supportively. Suctioning airway secretions is critical because pain from rib movement discourages coughing, leading to mucus retention and potential atelectasis or pneumonia. This intervention clears the airway, supports ventilation, and prevents complications, aligning with the goal of maintaining respiratory function. Immobilizing ribs with a binder restricts breathing, worsening oxygenation, and is contraindicated. Surgery is rare and reserved for severe cases with large flail segments or internal damage. Immediate sedation and intubation are unnecessary for a small injury unless respiratory failure ensues, which isn't indicated here. The nurse's focus on secretion clearance via suctioning, alongside pain control and breathing exercises, optimizes recovery in this trauma patient.

Correct Answer: B

Rationale: Preventing hospital-acquired pneumonia (HAP), a nosocomial infection occurring 48+ hours post-admission, relies on targeting vulnerable populations, making pneumococcal vaccination a key measure. This vaccine protects against Streptococcus pneumoniae, a leading HAP cause, reducing incidence in older adults or those with chronic illnesses, as supported by CDC guidelines for adults over 65 or with comorbidities. Prophylactic antibiotics aren't standard due to resistance risks and lack of evidence for broad prevention. Routine culture swabs on admission identify pathogens but don't prevent infection, serving more for treatment guidance. Antiretrovirals address HIV, not bacterial pneumonia, and aren't indicated here. Vaccination strengthens immunity in at-risk patients (e.g., elderly, immunocompromised), decreasing HAP rates, hospitalizations, and mortality, aligning with infection control priorities in healthcare settings.

Correct Answer: D

Rationale: Post-embolectomy for pulmonary embolus (PE), the nurse most closely monitors pulmonary arterial pressure (PAP) via a pulmonary artery catheter, as it directly reflects the procedure's success in relieving pulmonary vascular obstruction. Elevated PAP pre-surgery indicates blockage; post-surgery, a decrease signals clot removal efficacy, while persistent elevation suggests residual emboli or reperfusion issues, guiding further intervention (e.g., thrombolytics). Pupillary response assesses neurological status, irrelevant unless cerebral hypoxia occurred. Vena cava pressure isn't routinely monitored and lacks specificity for PE outcomes. White blood cell differential tracks infection or inflammation, not acute hemodynamic status. PAP monitoring, alongside urinary output for perfusion, equips the nurse to detect complications (e.g., re-embolization), ensuring optimal postoperative management in this critical ICU patient.

Correct Answer: C

Rationale: Bilateral wheezes are the assessment finding most closely tied to asthma's characteristic symptoms cough, dyspnea, and wheezing reflecting airflow obstruction from bronchospasm, inflammation, and mucus. Wheezing, a high-pitched sound on expiration (and sometimes inspiration), arises as air squeezes through narrowed airways, a hallmark audible in both lungs during an attack. Shallow respirations occur but aren't specific, lacking the obstructive quality of wheezes. Increased A-P diameter (barrel chest) develops in chronic COPD, not typically in pediatric asthma unless severe and longstanding. Bradypnea, slow breathing, contradicts asthma's tachypnea from air hunger. The nurse's detection of bilateral wheezes confirmed by auscultation guides acute management (e.g., bronchodilators), aligning with asthma's reversible, inflammatory pathophysiology in this child.