Correct Answer: C

Rationale: Rationale for Correct Answer (C - Assess the cuff for proper arm size): 1. The cuff blood pressure (70/40 mm Hg) is significantly lower than the arterial blood pressure (108/70 mm Hg). 2. Discrepancy suggests cuff size mismatch, leading to inaccurate readings. 3. Assessing cuff size ensures accurate blood pressure measurement. 4. Ensures appropriate interventions based on accurate readings. Summary of Incorrect Choices: A: Rapid response not warranted based solely on blood pressure discrepancy. B: Trendelenburg position not indicated for cuff size issue. D: Normal saline bolus not appropriate without accurate blood pressure measurement.

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: C

Rationale: Step 1: Comfort care is focused on providing relief from suffering and improving quality of life. Step 2: Patient-centered care emphasizes the individual's preferences and values. Step 3: Patient autonomy is a fundamental principle in healthcare decision-making. Step 4: Patients have the right to determine what constitutes comfort care for themselves. Step 5: Therefore, statement C is correct as it aligns with the patient's autonomy and individualized care approach. Summary: - Choice A is incorrect because legal distinctions between withholding and withdrawing treatment may vary. - Choice B is incorrect as it focuses on evaluating procedures rather than the patient's preferences. - Choice D is incorrect as withdrawing life-sustaining treatments is not universally considered euthanasia.

Correct Answer: B

Rationale: The correct answer is B. Implementing a comprehensive oral care program is an intervention for preventing VAP. This statement is true because proper oral care, including brushing teeth, oral suctioning, and using chlorhexidine gluconate, has been shown to reduce the risk of VAP by decreasing the colonization of pathogenic bacteria in the oral cavity. Regular oral care helps maintain oral hygiene and reduce the risk of aspiration of bacteria into the lungs, which is a common cause of VAP. Incorrect Answer Analysis: A: Tooth brushing every 2 hours may be excessive and could potentially cause harm to the oral mucosa, leading to increased risk of infection. C: While oral suctioning and brushing teeth are important components of oral care, the statement is not comprehensive enough to address the full range of interventions needed to prevent VAP. D: While chlorhexidine gluconate can be effective in preventing VAP, the statement implies that it is the only effective intervention, which is not true.

Correct Answer: C

Rationale: The correct answer is C: Severe pain. In the second phase of the stress response (resistance phase), the body is trying to cope with the stressor. Severe pain is a sign of the body's response to the injury, indicating the activation of the stress response. Labored breathing and elevated heart rate are more likely to be signs of the initial phase (alarm phase) of the stress response. Bleeding heavily from the abdomen is a medical emergency and does not specifically indicate the stress response phase.