Correct Answer: C

Rationale: The correct answer is C: Suggesting that he meet with the hospital chaplain. This approach is best as it addresses the young man's emotional and spiritual needs during a difficult time. The chaplain can provide comfort, support, and guidance in coping with his girlfriend's situation. This option focuses on holistic care and acknowledges the importance of emotional well-being. A: Recommending that he go home and rest is not the best approach as it dismisses the young man's emotional distress. B: Giving him unrestricted visiting hours with the patient may not be appropriate as it can be overwhelming and may not address his emotional needs effectively. D: Recommending that he ask the doctor to evaluate the patient's pain control measures is important but does not directly address the young man's emotional needs in this situation.

Correct Answer: D

Rationale: The correct answer is D. The patient receiving IV heparin with a PTT of 98 seconds is at risk for bleeding due to the therapeutic range of 60-80 seconds. Assessing this patient first is crucial to prevent potential bleeding complications. A high PTT indicates the blood is not clotting properly, increasing the risk of bleeding. Prompt assessment and possible adjustment of heparin infusion are needed. A: The patient with a temperature of 101.4°F may have a fever but is not at immediate risk compared to the patient with a high PTT. B: The patient on BiPAP with a respiratory rate of 16 is stable and does not require immediate assessment. C: The patient post-percutaneous coronary intervention needing to void is a routine need and does not require immediate attention compared to the patient with a critical lab value.

Correct Answer: B

Rationale: The correct answer is B because developing a standardized reporting form for family information that is incorporated into the patient's medical record ensures consistency and accuracy in sharing vital details about family structure and dynamics from shift to shift. This method allows all healthcare providers to access the information easily and update it as needed, promoting continuity of care and comprehensive understanding of the family's needs. Choices A, C, and D are incorrect because: A: Creating an informal family information sheet may lead to inconsistencies in the information shared among healthcare providers and may not be updated regularly. C: Requiring only the charge nurse to have detailed information may result in information silos and lack of accessibility for all team members. D: Discussing family dynamics as part of the change-of-shift report may lead to important details being missed or forgotten, compromising the quality of care provided.

Correct Answer: C

Rationale: The correct answer is C (80 mL/hour) because the minimum acceptable urine output for a patient is approximately 0.5-1 mL/kg/hour. For a 75 kg patient, this equates to 37.5-75 mL/hour. Therefore, an output of 80 mL/hour is within this range and is considered minimally acceptable. A: Less than 30 mL/hour is incorrect because it is below the recommended range for a 75 kg patient. B: 37 mL/hour is close to the lower end of the acceptable range, but it is not the minimum acceptable output. D: 150 mL/hour is above the recommended range and would be considered excessive for a 75 kg patient.

Correct Answer: B

Rationale: The correct answer is B: Assess neurological status every 30 minutes. This intervention is crucial for patients receiving neuromuscular blocking agents to monitor for any adverse effects such as respiratory depression or paralysis. Regular assessments help ensure early detection of complications and prompt intervention. A: Administering sedatives in conjunction with neuromuscular blocking agents can potentiate respiratory depression and lead to respiratory compromise. C: Avoiding interaction with the patient is not appropriate as communication and patient interaction are important aspects of nursing care. D: Restraint should be avoided as it can increase the risk of complications such as pressure ulcers, anxiety, and decreased respiratory function. Overall, regular neurological assessments are essential for ensuring patient safety and prompt intervention in case of any complications.