The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which action will be most appropriate for the nurse to take?

Correct Answer: C

Rationale: The correct answer is C: Measure and record all intake and output. This action is most appropriate for monitoring fluid and electrolyte balance in a postoperative patient as it helps to assess if the patient is receiving adequate fluids and excreting appropriately. By measuring and recording intake and output, the nurse can identify any imbalances and take necessary interventions. Encouraging copious amounts of water (A) without monitoring intake and output can lead to fluid overload or imbalance. Starting an additional IV line (B) may not be necessary if the patient's current IV is functioning properly. Weighing the patient and comparing with preoperative weight (D) is important but may not provide real-time information on fluid and electrolyte balance.

Correct Answer: C

Rationale: The correct answer is C: Remove the BVM from tube #1 and ventilate through tube #2. This is the correct action because the presence of gastric sounds indicates that the tube is likely in the esophagus, not the trachea. By removing the BVM from tube #1 and ventilating through tube #2, you are ventilating the patient's lungs directly, improving oxygenation. Choice A is incorrect because ventilating through tube #1 will not improve the patient's condition if the tube is in the esophagus. Choice B is incorrect because confirming placement with a CO2 detector before ventilating through tube #1 does not address the issue of gastric sounds indicating esophageal placement. Choice D is incorrect because pulling the combi-tube back 2 cm without addressing the issue of esophageal placement will not improve ventilation.

Correct Answer: B

Rationale: The correct answer is B: Inferior wall. ST elevation in Leads II, III, aVF indicates an inferior wall myocardial infarction, commonly caused by occlusion of the right coronary artery. Lead II views the inferior part of the heart, and Leads III/aVF view the inferior and posterior parts. This pattern suggests damage to the inferior wall supplied by the right coronary artery. Other choices are incorrect as ST elevation in these leads does not correspond to lateral (A), anterior (C), or septal (D) wall infarctions.

Correct Answer: C

Rationale: Congestive heart failure is most likely to cause problems with both internal (heart's pumping ability) and external (lung function) processes of respiration. Step 1: In CHF, the heart struggles to pump blood effectively, leading to fluid accumulation in the lungs (internal process). Step 2: The fluid in the lungs impairs gas exchange, affecting oxygenation and carbon dioxide elimination (external process). Step 3: This dual impact on internal and external respiration distinguishes CHF from other choices (lung cancer, hypertension, emphysema).

Correct Answer: B

Rationale: The correct answer is B: Negligence charges could be brought against the paramedic in charge of the unit. Rationale: 1. Negligence: In this scenario, the paramedic failed to ensure the equipment was properly charged, leading to the death of the patient. 2. Duty of Care: The paramedic had a duty to ensure the equipment was functional to provide appropriate care to the patient. 3. Breach of Duty: By not ensuring the defibrillator had adequate battery power, the paramedic breached their duty of care. 4. Proximate Cause: The lack of functioning equipment directly contributed to the patient's death. 5. Legal Liability: Negligence in providing care can result in legal charges being brought against the individual responsible for the patient's care. Summary: A: Manslaughter charges are not applicable as there was no intent to harm the patient. C: Battery charges are not relevant as it refers to physical harm, not the lack of battery power in equipment