The nurse is caring for a patient in the postanesthesia care unit. The patient asks for a bedpan and states to the nurse, " feel like I need to go to the bathroom, but I can't." Which nursing intervention will be most appropriate initially?

Correct Answer: A

Rationale: The correct answer is A: Assess the patient for bladder distention. This is the most appropriate initial intervention because the patient is experiencing a sensation of needing to urinate but is unable to. Bladder distention is a common issue after surgery due to the effects of anesthesia and reduced mobility. By assessing for bladder distention, the nurse can determine if the patient needs assistance with voiding or if there is a more serious issue such as urinary retention. Encouraging the patient to wait or informing them that this feeling is normal could potentially worsen the situation. Calling the healthcare provider for catheterization should only be done after assessing the patient's bladder status.

Correct Answer: D

Rationale: The correct answer is D: Narcotic overdose. The patient's presentation of increased respirations, hypotension, and bradycardia is consistent with opioid overdose. Opioids such as Vicodin can cause respiratory depression leading to increased respirations, hypotension, and bradycardia. In contrast, myasthenia gravis would present with muscle weakness, metabolic alkalosis is unlikely to present with this combination of symptoms, and ketoacidosis is more commonly associated with uncontrolled diabetes rather than opioid overdose. Therefore, a narcotic overdose is the most likely cause of the patient's presentation.

Correct Answer: B

Rationale: The correct answer is B: An inferior wall myocardial infarction. The ST elevation in leads II, III, and aVf indicates involvement of the inferior wall of the heart. This pattern is classic for an inferior wall MI. The chest pain radiating to the jaw and left arm is also suggestive of cardiac origin. Aortic dissection typically presents with severe tearing or ripping chest pain and may have unequal blood pressure in the arms. Pulmonary embolism usually presents with sudden-onset dyspnea and chest pain, often worsened by deep breathing or coughing. A septal wall MI would typically present with ST elevation in leads V1-V2.

Correct Answer: C

Rationale: The correct answer is C: She is an emancipated minor granted by the court. An emancipated minor is legally considered an adult and can make medical decisions without parental consent. This situation would make the statement true because an emancipated minor has the legal authority to consent to their own treatment. Rationale: 1. Emancipated minors are legally recognized as adults in terms of making medical decisions. 2. Emancipation grants the minor the right to make healthcare choices independently. 3. In this scenario, the patient being an emancipated minor means she can consent to treatment without involving her parents. Summary of other choices: A: Implied consent does not apply in this scenario as the patient is conscious and alert, and the injury is not immediately life-threatening. B: Immigration status is not relevant to the patient's ability to consent to treatment without parental consent. D: Being an orphaned minor does not automatically grant the ability to consent to treatment without parental consent.

Correct Answer: B

Rationale: The correct answer is B: To prevent atelectasis from occurring at the end of exhalation. Pursed lips and sighing respirations help create positive end-expiratory pressure (PEEP) in the airways, preventing alveolar collapse and promoting gas exchange. Pursed lips maintain airway patency, while sighing helps to recruit collapsed alveoli. A: Incorrect - Pursed lips and sighing are not related to expelling foreign bodies or irritants from the lower airway. C: Incorrect - Pursed lips and sighing are not associated with preventing pleural friction rub or pleurisy. D: Incorrect - Pursed lips and sighing do not directly increase the size of the air sacs in the lungs to improve oxygenation.