A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?

Correct Answer: A

Rationale: The correct answer is A: Allow family members to remain at the bedside. This is the priority action as it provides emotional support and comfort to the client. Having familiar faces around can help calm the client and reduce agitation. It also promotes a sense of security and connection. Choices B, C, and D are incorrect because they do not address the client's immediate need for comfort and emotional support. Asking about a fan, tuning the TV, or speaking loudly do not directly address the client's restlessness and agitation. Prioritizing the presence of family members is essential in this situation.

Correct Answer: B

Rationale: The correct answer is B (Expired food found in the refrigerator) because it poses a potential health risk to the client. Expired food can lead to foodborne illnesses, especially for an older adult post-surgery. Dirty carpets (choice A) may not directly impact the client's health. Outdated medications (choice C) can be addressed by the nurse without additional referrals. The presence of multiple cats (choice D) may be a concern for allergies or cleanliness, but it is not as urgent as expired food in terms of health risks.

Correct Answer: C

Rationale: The correct answer is C: 1630 (4:30 PM). The rationale is as follows: 1. The standard guideline for performing percutaneous coronary intervention (PCI) in acute MI is within 90 minutes of arrival at the hospital. 2. The client arrived at 1500 (3:00 PM), so adding 90 minutes to this time gives us 1630 (4:30 PM). 3. This timing aligns with The Joint Commission's Core Measures for timely PCI in acute MI cases. 4. Therefore, the correct time for the client to have PCI performed is 1630 (4:30 PM). In summary, choices A, B, and D are incorrect because they do not align with the 90-minute guideline for performing PCI in acute MI cases, as mandated by The Joint Commission's Core Measures.

Correct Answer: C

Rationale: The correct answer is C: It increases the force of the heart's contractions. Inotropic agents are medications that enhance the strength of the heart's contractions, improving cardiac output. This explanation is accurate because inotropic agents work by increasing the contractility of the heart muscle, leading to stronger contractions and improved pumping ability. Explanation for why the other choices are incorrect: A: It constricts vessels, improving blood flow - This is incorrect because inotropic agents primarily affect the heart's contractility, not vascular constriction. B: It dilates vessels, which lessens the work of the heart - This is incorrect because inotropic agents do not primarily dilate vessels; their main action is on the heart's contractility. D: It slows the heart rate down for better filling - This is incorrect because inotropic agents do not slow down the heart rate; they increase the force of contractions. In summary, choice C is correct as inotropic agents increase the force of

Correct Answer: A

Rationale: The correct answer is A: Assess the client's lung sounds. This is important because after a myocardial infarction, there is a risk of pulmonary edema, which can present as crackles or wheezes in the lungs. By assessing the lung sounds, the healthcare provider can identify any signs of respiratory distress and promptly intervene if necessary. Choice B is incorrect because calling the Rapid Response Team is not warranted based solely on abnormal heart sounds. Choice C is incorrect as having the client sit upright is not directly related to addressing abnormal heart sounds. Choice D is also incorrect as it focuses solely on assessing lung sounds without considering the potential implications of the abnormal heart sounds.