Correct Answer: B

Rationale: The correct answer is B: Train-of-four yields two twitches. This assessment indicates a target level of paralysis because a train-of-four ratio of 2 twitches out of 4 suggests a 50% neuromuscular blockade, which is often the goal for patients receiving paralysis for procedures or ventilation. A: A Glasgow Coma Scale score of 3 assesses consciousness, not neuromuscular blockade. C: A Bispectral index of 60 measures depth of anesthesia, not paralysis level. D: CAM-ICU assesses delirium, not neuromuscular blockade.

Correct Answer: C

Rationale: Rationale: C: Providing the patient with 5 minutes of effleurage (gentle massage) and minimizing disruptions is the most helpful intervention. Effleurage can help reduce anxiety and promote relaxation, improving sleep quality. Minimizing disruptions creates a conducive environment for sleep. A: Providing a bath after REM sleep may disrupt the patient's sleep cycle, worsening anxiety. B: Increasing pain medication may not address the root cause of anxiety and could lead to dependency or side effects. D: Monitoring brain waves with polysomnography is an invasive procedure not typically indicated for managing anxiety-related sleep issues.

Correct Answer: A

Rationale: The correct answer is A: Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change. This is because inflating the balloon within this time frame allows for accurate measurement of PAOP without causing complications like pulmonary edema. Noting the waveform change helps in determining the accurate pressure reading. Explanation of why other choices are incorrect: B: Inflating the balloon with air and recording the volume necessary is not a recommended practice as it can lead to inaccurate readings and potential harm to the patient. C: Maintaining the balloon inflated for 8 hours following insertion is unnecessary and could lead to complications such as vascular damage or thrombosis. D: Zero referencing and leveling the transducer at the phlebostatic axis are important steps but not directly related to performing an initial PAOP measurement.

Correct Answer: C

Rationale: The correct answer is C: Treatment for elevated blood pressure. In the initial stress response, the body releases adrenaline and cortisol, leading to increased heart rate and blood pressure. Treating elevated blood pressure is crucial to prevent complications like heart attack or stroke. Adequate pain control (A) and intravenous sedation (B) may help manage symptoms but do not directly address the physiological response to stress. Ignoring an elevated glucose level (D) is not recommended as stress can impact blood sugar levels. Treatment for elevated blood pressure directly targets the physiological response to stress, making it the best nursing action in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Hypoventilation and respiratory acidosis. When a patient overdoses on sedatives, it can lead to respiratory depression causing hypoventilation. Hypoventilation results in retention of CO2, leading to respiratory acidosis. This is because the body is not effectively exhaling CO2, causing an increase in carbonic acid levels and a decrease in blood pH. The other choices are incorrect because hyperventilation would lead to respiratory alkalosis (Choice A), hypoventilation does not cause respiratory alkalosis (Choice C), and normal oxygen levels do not indicate the acid-base imbalance caused by sedative overdose (Choice D).