Correct Answer: C

Rationale: The correct answer is C: Notify the health care provider and postpone the transfer. The new onset confusion in an elderly patient in the ICU can be a sign of delirium, which is a serious condition that requires prompt evaluation and management. By notifying the healthcare provider, they can assess the patient's condition, order appropriate tests, and adjust the treatment plan as needed. Postponing the transfer allows for further observation and intervention to address the underlying cause of the confusion. Choice A (Give PRN lorazepam and cancel the transfer) is incorrect because administering lorazepam may worsen the confusion in an elderly patient and should not be done without proper evaluation. Choice B (Inform the receiving nurse and then transfer the patient) is incorrect because transferring the patient without addressing the new onset confusion can lead to potential complications and delay in appropriate management. Choice D (Obtain an order for restraints as needed and transfer the patient) is incorrect because using restraints should only be considered as a

Correct Answer: D

Rationale: The correct answer is D: Determine the patient’s work of breathing. Assessing the exhaled tidal volume (EV) in a mechanically ventilated patient helps determine how much effort the patient is exerting to breathe. By monitoring the EV, the nurse can evaluate the patient's respiratory status and adjust ventilator settings if needed. It is crucial to ensure that the patient is not working too hard to breathe, as this can lead to respiratory distress. Incorrect answers: A: Assess for tension pneumothorax - Tension pneumothorax is typically assessed through other means such as physical examination and chest X-ray. B: Assess the level of positive end-expiratory pressure - The level of positive end-expiratory pressure is usually set based on the patient's condition and not solely based on the exhaled tidal volume. C: Compare the tidal volume delivered with the tidal volume prescribed - This comparison is important but does not directly relate to assessing the patient's work of breathing.

Correct Answer: B

Rationale: The correct answer is B: Offering the patient a patient-controlled analgesic device. This intervention allows the patient to self-administer pain relief, which can help alleviate discomfort associated with mechanical ventilation and reduce agitation. Breathing exercises (choice A) may not address the root cause of agitation. Asking for antianxiety medication (choice C) may not be immediate or ideal due to potential side effects. Offering an MP3 player (choice D) may provide distraction but may not effectively address the agitation caused by the ventilator.

Correct Answer: B

Rationale: The correct answer is B because sitting at the bedside and asking if there is anything the patient needs demonstrates empathy and support. It allows the patient to express their concerns and fears, providing emotional comfort. It shows the nurse is actively listening and willing to help address any immediate needs or concerns. Choice A is incorrect because it dismisses the patient's feelings and may come across as invalidating. Choice C is incorrect because insisting that family members remain may not be what the patient needs at that moment and could cause additional stress. Choice D is incorrect because it does not address the patient's emotional distress and may not be true in the context of terminal illness.

Correct Answer: B

Rationale: The correct short-term goal for the client with imbalanced nutrition is choice B: Eat 50% of six small meals each day by the end of one week. This goal is specific, measurable, achievable, relevant, and time-bound (SMART). By setting a goal for the client to eat a specific amount of meals within a defined timeframe, it allows for objective monitoring of progress. This goal also addresses the client's decreased intake and aims to improve their nutritional status gradually. Choice A is incorrect as verbalizing understanding does not directly address the client's nutritional needs. Choice C is not appropriate as it does not promote independence in meal consumption. Choice D is not the best short-term goal as it focuses on the outcome of weight gain rather than the process of increasing food intake. Overall, choice B is the most appropriate short-term goal as it targets the client's specific nutritional needs and provides a clear direction for intervention.