The patient has an order for Percocet 2 tabs qh prn for pain.

Based on the label below, if the patient takes 2 tabs every 6 hours, how much acetaminophen will the patient take in 24 hours? 

Choice A rationale

Acknowledging the frightening nature of the illness is a crucial therapeutic communication technique. By validating the patient's feelings of fear and anxiety, the nurse establishes trust and rapport. This approach shows empathy and helps the patient feel understood, which can reduce psychological distress. It also provides a foundation for the patient to be more receptive to subsequent nursing interventions and education.

Choice B rationale

Providing simple, clear explanations of what is happening helps to demystify the situation and reduce the patient's anxiety. When a person is anxious, their cognitive processing can be impaired, making it difficult to comprehend complex information. Short, concise explanations about the cause of their symptoms and the purpose of interventions can help the patient feel more in control and less overwhelmed, thereby alleviating some of their fear.

Choice C rationale

Requesting a prescription for antianxiety medications is not the most appropriate immediate action. While medications may eventually be necessary, the initial nursing actions should focus on non-pharmacological interventions. These include therapeutic communication and supportive presence. Pharmacological interventions are typically reserved for situations where non-pharmacological methods are insufficient or the anxiety is severe enough to cause physiological instability.

Choice D rationale

Staying with the patient and speaking in a quiet, calm voice is a primary nursing action for an anxious patient. A calm, reassuring presence can help to de-escalate the patient's anxiety by providing a sense of security and support. The nurse's calm demeanor can also model appropriate emotional regulation for the patient, which can help to reduce their physiological and psychological distress. This action is simple, immediate, and highly effective.

Choice A rationale

A penetrating chest wound can lead to pneumothorax, hemothorax, or flail chest, all of which compromise the patient's ability to breathe and exchange gases effectively. The immediate and most life-threatening consequence is acute respiratory failure. Therefore, the highest priority goal is to restore adequate gas exchange to ensure proper oxygenation of the blood and removal of carbon dioxide. This goal supersedes all others.

Choice B rationale

While effective coping is important for a patient with a long-term illness or injury, it is a psychosocial goal that is not prioritized over the immediate physiological need for life support. Coping mechanisms cannot be addressed until the patient's immediate and life-threatening medical conditions, such as respiratory failure, are stabilized.

Choice C rationale

Facilitation of long-term intubation is not a primary goal of treatment; rather, it is a potential intervention to achieve the primary goal of restoring gas exchange. The ultimate goal is to wean the patient off mechanical ventilation and extubate them as soon as medically possible, not to keep them on the ventilator long-term. The intervention is a means to an end, not the end itself.

Choice D rationale

Self-management of oxygen therapy is a long-term goal that is only applicable to patients who survive the acute phase of their illness and require supplemental oxygen at home. This goal is not appropriate for a patient in acute respiratory failure in a hospital setting. The immediate priority is the stabilization of the patient and restoration of normal respiratory function, not patient education for home care