A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional assessment finding would the nurse expect?

Correct Answer: B

Rationale: The correct answer is B: Cool, clammy skin. Following a myocardial infarction, the client may experience hypotension due to decreased cardiac output. Cool, clammy skin indicates poor peripheral perfusion, a common manifestation of hypotension. This finding suggests inadequate blood flow to the skin. The other choices are incorrect because: A: A heart rate of 120 beats/min may indicate tachycardia, which is a compensatory mechanism to maintain cardiac output in response to hypotension. C: An oxygen saturation of 90% is below the normal range but is not a typical assessment finding related to hypotension after a myocardial infarction. D: A respiratory rate of 8 breaths/min is abnormally low but not directly related to hypotension post-myocardial infarction.

Correct Answer: C

Rationale: The correct answer is C: Is the delegated task permitted by law? This is the first question the nurse must ask before delegating medication administration to an unskilled assistant. The rationale is that delegation must comply with legal regulations to ensure patient safety and avoid legal implications. If the task is not permitted by law, the nurse should not delegate it. Choice A (Has the assistant been trained to perform the task?) is important but comes after ensuring the task is legally permitted. Choice B (Have I evaluated the patients response to this task?) is about patient assessment, not legality. Choice D (Is appropriate supervision available?) is relevant but should come after confirming the task's legality.

Correct Answer: C

Rationale: The primary focus of healthcare today is health promotion (Choice C) because it emphasizes preventive measures to maintain overall well-being and reduce the burden of diseases. Health promotion involves educating individuals on healthy lifestyle choices, disease prevention, and early detection. This approach aligns with the shift towards proactive rather than reactive healthcare. Incorrect options: A: Care of acute illnesses - This option focuses on treating immediate health issues rather than preventing them. B: Care of chronic illnesses - While important, this option addresses managing ongoing conditions rather than prioritizing prevention. D: Health restoration - This choice emphasizes restoring health after illness, which is essential but not the primary focus of healthcare today.

Correct Answer: D

Rationale: The correct answer is D because discharge planning aims to ensure that the patient and their family's needs are consistently met post-discharge. This process involves assessing the patient's health status, identifying resources for continued care, and creating a plan to support the patient's transition from the healthcare facility to the home environment. By addressing the physical, emotional, and social needs of the patient and family, healthcare providers can enhance continuity of care, reduce readmission rates, and improve overall patient outcomes. Choice A is incorrect because discharge planning focuses on the post-acute care setting, not the acute care setting. Choice B is incorrect as documenting nursing care is part of the overall patient care process but not the primary rationale for discharge planning. Choice C is incorrect as discharge planning involves assessing available resources and support systems, which may or may not involve family members providing home care.

Correct Answer: C

Rationale: The correct answer is C because it follows the recommended guidelines for documenting data by being factual, objective, and specific. It includes a clear cause and effect relationship between the intervention (oxygen administration) and the outcome (vital signs returning to baseline). This type of documentation is essential for accuracy, continuity of care, and legal purposes. A, B, and D are incorrect because they contain subjective interpretations, lack specificity, and do not provide clear cause-effect relationships. A is subjective, B lacks specificity, and D involves subjective interpretation of patient behavior. Such entries can lead to miscommunication, misunderstanding, and compromised patient care.