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 nursing intervention because the patient is expressing a need to urinate but is unable to. Assessing for bladder distention will help determine if the patient's inability to void is due to a full bladder, which may require intervention such as catheterization. Choice B is incorrect because encouraging the patient to wait may lead to discomfort or potential complications if the bladder is distended. Choice C is incorrect as it dismisses the patient's concern without addressing the underlying issue. Choice D is also incorrect as catheterization should not be the first intervention without assessing for bladder distention first.

Correct Answer: D

Rationale: The correct answer is D: Narcotic overdose. The patient's presentation of increased respirations, hypotension, and bradycardia is consistent with narcotic overdose, specifically from Vicodin, which contains hydrocodone. Narcotics can cause respiratory depression leading to increased respirations as a compensatory mechanism, hypotension due to vasodilation, and bradycardia. Myasthenia gravis (A) would present with muscle weakness, not the symptoms described. Metabolic alkalosis (B) would not typically present with the combination of symptoms described. Ketoacidosis (C) is more commonly associated with uncontrolled diabetes and would present with different symptoms such as fruity breath, dehydration, and altered mental status.

Correct Answer: B

Rationale: The correct answer is B: An inferior wall myocardial infarction. The EKG findings of ST elevation in leads II, III, and aVf indicate an inferior wall MI. Leads II, III, and aVf correspond to the inferior wall of the heart supplied by the right coronary artery. This pattern of ST elevation is indicative of myocardial ischemia or infarction in this region. The symptoms of chest pain radiating to the jaw and left arm are also classic for a heart attack. A: A possible aortic dissection is unlikely in this case as the EKG findings specifically point towards a myocardial infarction rather than aortic pathology. C: A possible pulmonary embolus is less likely as the EKG findings are more consistent with a myocardial infarction, and pulmonary embolism typically presents with symptoms such as shortness of breath and chest pain. D: A septal wall myocardial infarction is not supported by the

Correct Answer: C

Rationale: The correct answer is C: She is an emancipated minor granted by the court. This is true because an emancipated minor is legally recognized as an adult and can make medical decisions without parental consent. Emancipation typically requires a court order that grants the minor the legal status of an adult. In this case, the patient is sixteen and does not need parental consent because she has been granted emancipation by the court. Choice A (implied consent) is incorrect because implied consent generally applies in emergency situations where the patient is unable to provide consent. In this case, the patient is conscious and capable of providing consent. Choice B (not an American citizen) is incorrect because citizenship status does not impact a minor's ability to provide consent for medical treatment. Choice D (orphaned minor living alone) is incorrect because being orphaned does not automatically grant a minor the legal status to make medical decisions 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-type respirations help create positive pressure in the airways, preventing collapse of small airways and maintaining lung inflation. Pursed lips prolong exhalation, which helps keep airways open, reducing the risk of atelectasis. Choices A, C, and D are incorrect because pursed lips and sighing-type respirations do not directly relate to expelling foreign bodies, preventing pleural friction rub, or increasing the size of air sacs in the lungs.