Correct Answer: C

Rationale: The correct answer is C: High resolution multidetector CT angiogram. This diagnostic procedure is required for a definitive diagnosis of pulmonary embolism because it provides detailed imaging of the pulmonary vasculature, allowing visualization of blood clots in the pulmonary arteries. A: Arterial blood gas (ABG) analysis does not directly diagnose pulmonary embolism but may show signs of hypoxemia or respiratory alkalosis, which can be seen in some cases of pulmonary embolism. B: Chest x-ray examination may show nonspecific findings such as atelectasis or pleural effusion but cannot definitively diagnose pulmonary embolism. D: Ventilation-perfusion scanning is another imaging modality used in the diagnosis of pulmonary embolism, but it is less commonly used compared to CT angiogram due to lower sensitivity and specificity.

Correct Answer: C

Rationale: The correct answer is C: Notify the organ procurement organization (OPO). This is the best action because the OPO is responsible for coordinating organ donation and transplantation. By involving the OPO, the nurse ensures that the donation process is handled appropriately and ethically. Choice A: Arranging a multidisciplinary meeting with physicians may be necessary but should not be the first step in this situation. Choice B: Consulting the hospital’s ethics committee may be helpful, but the immediate priority is to involve the OPO to facilitate organ donation. Choice D: Obtaining family consent to withdraw life support is not the nurse’s role in this situation. The focus should be on organ donation to honor the family's wishes.

Correct Answer: C

Rationale: The correct answer is C because BIS and PSI monitors provide both raw EEG data and a numeric value, simplifying the interpretation of patient sedation levels. Raw EEG data offers detailed information on brain activity, while the numeric value allows for quick assessment. This simplifies the monitoring process compared to interpreting raw EEG data alone. Choice A is incorrect as BIS and PSI monitors are not restricted to heavily sedated patients. Choice B is incorrect as they are not limited to pediatric patients. Choice D is incorrect as the number of leads required does not determine the simplicity of use; it is the data interpretation that matters.

Correct Answer: D

Rationale: The correct answer is D: Richmond Agitation Sedation Scale (RASS). RASS is specifically designed to monitor agitation and sedation levels in critically ill patients, providing a standardized and objective assessment. It includes clear descriptors for different levels of agitation and sedation, allowing for consistent monitoring and treatment adjustments. CAM-ICU is mainly used for delirium assessment, not agitation. FACES assessment tool is more appropriate for pain assessment. Glasgow Coma Scale is focused on assessing level of consciousness, not agitation specifically. By using RASS, healthcare providers can accurately track agitation levels and evaluate the effectiveness of interventions in managing agitation in critically ill patients.

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.