The nurse is caring for a mechanically ventilated patient following bilateral lung transplantation. When planning the care of this patient, what is the priority nursing intervention?

Correct Answer: A

Rationale: The correct answer is A: Thirty-degree elevation of the head of the bed. This is the priority nursing intervention for a mechanically ventilated patient following bilateral lung transplantation because it helps optimize ventilation-perfusion matching, reduces the risk of aspiration, and improves oxygenation. Elevating the head of the bed also decreases the risk of ventilator-associated pneumonia. B: Endotracheal suctioning as needed is important but not the priority intervention in this case. C: Frequent side to side repositioning is important for preventing pressure ulcers but is not the priority for a ventilated patient post-lung transplant. D: Sequential compression stockings are used for preventing deep vein thrombosis, which is important but not the priority in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Bilateral infiltrates on chest x-ray study. ARDS diagnosis requires bilateral infiltrates on chest x-ray, indicative of non-cardiogenic pulmonary edema. Choice B, decreased cardiac output, is not a diagnostic criterion for ARDS. Choice C, PaO2/FiO2 ratio of less than 200, is a key diagnostic criteria for ARDS, indicating severe hypoxemia. Choice D, PAOP of more than 18 mm Hg, is used to differentiate between cardiogenic and non-cardiogenic causes of pulmonary edema, but it is not a direct diagnostic criterion for ARDS.

Correct Answer: B

Rationale: The elevated BUN and creatinine levels with a normal BUN/creatinine ratio indicate impaired kidney function. This pattern is commonly seen in acute kidney injury, such as acute tubular necrosis (ATN). In ATN, there is damage to the renal tubules leading to decreased excretion of waste products, resulting in elevated BUN and creatinine levels. The normal BUN/creatinine ratio suggests that the impairment is due to renal tubular dysfunction rather than prerenal causes like hypovolemia or postrenal causes like urinary obstruction. Increased nitrogen intake would not produce this specific pattern of results. Fluid resuscitation would likely result in dilution of BUN and creatinine levels, leading to lower values.

Correct Answer: B

Rationale: The correct answer is B because a mechanically ventilated patient with cardiogenic shock being treated with an intra-aortic balloon pump would benefit most from having a Vigileo pulse contour cardiac output monitoring system. This device provides continuous cardiac output monitoring and can help guide hemodynamic management in critically ill patients, especially those with hemodynamic instability like cardiogenic shock. It allows for real-time adjustments of fluid and vasoactive medications to optimize cardiac output and tissue perfusion. Choice A is incorrect because a patient with a history of aortic insufficiency and postoperative myocardial infarction may not require continuous cardiac output monitoring like the patient in choice B. Choice C is incorrect as the patient with atrial fibrillation and paroxysmal supraventricular tachycardia does not necessarily need cardiac output monitoring. Choice D is also incorrect as a mechanically ventilated patient following repair of an acute bowel obstruction may not require continuous cardiac output monitoring unless there are specific complications.

Correct Answer: C

Rationale: Step 1: The objective is for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Step 2: Choice C states that the client drinks 240 mL of fluid five times during the shift, totaling 1200 mL (240 mL x 5) which exceeds the required amount. Step 3: Therefore, choice C is the correct answer as it demonstrates successful achievement of the objective by ensuring the client has ingested enough fluid within the specified time frame. Step 4: Choices A, B, and D are incorrect as they do not directly address the specific objective of fluid intake set for the client. Option A focuses on intake and output, option B relates to abdominal comfort, and option D is about voiding, none of which directly address the specified objective of fluid ingestion.

Correct Answer: A

Rationale: The correct answer is A: Unmarried life partners of same sex. When providing palliative care, it's crucial to recognize and respect diverse family structures. Unmarried life partners of the same sex may form a significant familial bond, requiring support and involvement in care decisions. This choice aligns with the principles of inclusivity and non-discrimination in palliative care. Incorrect choices: B: Unmarried life partners of the opposite sex - This choice is incorrect as it limits the definition of family to only opposite-sex partners, excluding same-sex couples. C: Roommates - While roommates may provide support, they do not necessarily have the same level of emotional and decision-making involvement as family members or life partners. D: Close friends - While close friends can be important sources of support, they do not necessarily have the same legal or emotional ties as a life partner.

Correct Answer: B

Rationale: The correct answer is B: Hypoventilation. A PaCO2 of 48 mm Hg indicates an elevated level of carbon dioxide in the blood, which is typically seen in hypoventilation where the lungs are not effectively removing CO2. Hypoventilation leads to respiratory acidosis. Option A is incorrect because hyperventilation would decrease PaCO2 levels. Option C is incorrect as it does not directly relate to PaCO2 levels. Option D is incorrect as increased excretion of HCO3- would not directly affect PaCO2 levels.

Correct Answer: C

Rationale: The correct response is C: Your pain medication is already at the highest possible dose. This response acknowledges the patient's pain and reassures them that they are already receiving the maximum safe amount of pain medication. By stating this, the nurse is validating the patient's experience and showing empathy. It is important for the nurse to communicate clearly about the medication to manage the patient's expectations. Choice A is incorrect as it dismisses the patient's pain and can come across as insensitive. Choice B may be well-intentioned but does not address the immediate concern of the patient's pain. Choice D is irrelevant to the patient's statement about pain and does not offer any immediate support or reassurance regarding the pain management.

Correct Answer: A

Rationale: The correct answer is A: Restlessness. Restlessness is a common behavioral indicator of anxiety in patients. In this scenario, a patient who is orally intubated and on a ventilator may not be able to verbally express anxiety, making restlessness a more prominent sign. Verbalization may not be possible due to intubation. While increased respiratory rate can be a symptom of anxiety, it is also a common physiological response in patients on mechanical ventilation. A Glasgow Coma Scale score of 3 indicates severe impairment of consciousness, not specifically anxiety.