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: The correct answer is C: Administer the dose as prescribed. Verapamil is a calcium channel blocker used to treat atrial flutter. The vital signs obtained are within normal range for this medication. A heart rate of 92 and blood pressure of 110/76 are not contraindications for administering verapamil. Option A is incorrect as calcium gluconate is not indicated in this situation. Option B is incorrect because the vital signs are stable and do not warrant withholding the medication. Option D is incorrect as there is no need to delay the administration of verapamil based on the vital signs provided.

Correct Answer: C

Rationale: The correct answer is C: Ptosis on the left eyelid. Ptosis refers to drooping of the eyelid, which is a common condition in older adults. In this scenario, the nurse should document the finding as ptosis on the left eyelid because the client's left upper eyelid is drooping, covering more of the iris than the right eyelid. Explanation: Nystagmus (A) is an involuntary eye movement, not related to eyelid drooping. Exophthalmos (B) is the protrusion of the eyeball and not relevant to this scenario. Astigmatism (D) refers to a refractive error of the eye and does not cause eyelid drooping. Therefore, the correct choice is C as it accurately describes the client's condition.

Correct Answer: C

Rationale: The correct answer is C: Damage to the type II pneumocytes, which produce surfactant. Acute respiratory distress syndrome (ARDS) is characterized by damage to the alveolar epithelium, including type II pneumocytes responsible for producing surfactant. Surfactant reduces surface tension in the alveoli, preventing collapse. Damage to type II pneumocytes impairs surfactant production, leading to alveolar collapse and impaired gas exchange. Choices A, B, and D are incorrect because ARDS is not primarily caused by a decrease in white blood cells, damage to the right mainstem bronchus, or decreased capillary permeability.

Correct Answer: A

Rationale: The correct answer is A: Evidence-based practice. The AACN Standards for Acute and Critical Care Nursing Practice emphasize the use of evidence-based practice to guide critical care nursing. This framework ensures that nursing interventions are based on the best available evidence, leading to improved patient outcomes. Healthy work environment (B) and National Patient Safety Goals (C) are important but not specific frameworks for critical care nursing. The nursing process (D) is a systematic approach to delivering patient care but is not the primary guiding framework in critical care nursing practice.