Correct Answer: D

Rationale: The correct answer is D - Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours. This patient should be assessed first because the absence of urine output for 6 hours after being extubated could indicate acute kidney injury or other serious complications that need immediate attention. Urine output is a crucial indicator of renal function and can reflect the patient's overall hemodynamic status. In contrast, the other choices do not present immediate life-threatening conditions. Choice A involves a patient in rest mode post-failed breathing trial, which does not require immediate assessment. Choice B mentions continuous PETCO2 monitoring, which is important but not as urgent as assessing a patient with no urine output. Choice C describes a patient with a ScvO2 of 69%, which may need monitoring but does not indicate an urgent priority compared to assessing a patient with no urine output after recent extubation.

Correct Answer: D

Rationale: Correct Answer: D - Give acetaminophen (Tylenol) 650 mg per nasogastric tube. Rationale: LPNs/LVNs are trained to administer medications, including oral and nasogastric routes. Giving acetaminophen via nasogastric tube is within their scope of practice. LPNs/LVNs should have the knowledge and skills to safely administer this medication as part of the hypothermia protocol. Summary of other choices: A: Continuously monitor heart rhythm - This requires specialized training and skills typically within the scope of registered nurses or cardiac monitoring technicians. B: Check neurologic status every 2 hours - Assessing neurologic status requires critical thinking and clinical judgment, which are typically responsibilities of registered nurses. C: Place cooling blankets above and below the patient - Positioning and managing cooling devices may require specific training and should be done under the supervision of a registered nurse.

Correct Answer: C

Rationale: The correct answer is C: True collaboration. In this scenario, the physician consults with the nurse to understand the situation and collaborates on the best course of action for the patient's care. This demonstrates effective teamwork, communication, and mutual respect between healthcare professionals, which are key components of a healthy work environment. Choice A (Skilled communication) is not the best answer because while communication between the physician and nurse is important, the focus in this scenario is more on collaboration and teamwork. Choice B (Appropriate staffing) is not the best answer as the scenario does not specifically address staffing levels but rather the interaction and collaboration between the physician and nurse. Choice D (Recognizing signs of imminent stroke and paging the physician) is incorrect as it is unrelated to the scenario described, which is about the physician and nurse collaborating on patient care.

Correct Answer: C

Rationale: The correct answer is C because a respiratory rate of 32 breaths/minute indicates increased work of breathing, which could be due to secretions that need to be suctioned. High respiratory rate may suggest inadequate oxygenation and ventilation. Oxygen saturation of 93% (choice A) is within an acceptable range and does not necessarily indicate the need for suctioning. Time since last suctioning (choice B) should be considered but is not as immediate an indication as an increased respiratory rate. Occasional audible expiratory wheezes (choice D) may be indicative of other respiratory issues but do not directly indicate the need for suctioning.

Correct Answer: C

Rationale: The correct answer is C because inquiring about specific cultural rituals and preferences shows respect for the patient's cultural beliefs and values. By asking about these aspects, the nurse can provide care that aligns with the patient's cultural background, promoting comfort and understanding. This action also demonstrates a commitment to individualized care. Choice A is incorrect because standardized care may not always be culturally appropriate. Choice B is incorrect as avoiding discussions about death can hinder effective communication and support. Choice D is incorrect as advising families to strictly follow hospital guidelines may overlook the importance of cultural considerations in end-of-life care.