Heparin is ordered for a patient with a non–ST-segment- elevation myocardial infarction (NSTEMI). How should the nurse explain the purpose of the heparin to the patient?

Correct Answer: C

Rationale: Step 1: Heparin is an anticoagulant medication that works by preventing the formation of new blood clots. Step 2: In NSTEMI, there is a risk of developing new clots in the coronary arteries, which can worsen the condition. Step 3: By explaining that heparin prevents the development of new clots, the nurse helps the patient understand the purpose of the medication in preventing further complications. Step 4: Option C is correct as it directly addresses the mechanism of action of heparin in NSTEMI. Step 5: Incorrect choices: A: Incorrect, as heparin does not enhance platelet aggregation but rather inhibits clot formation. B: Incorrect, as heparin does not decrease the size of coronary artery plaque. D: Incorrect, as heparin does not dissolve existing clots but prevents new clot formation.

Correct Answer: D

Rationale: The correct answer is D because a PaO2 level of 62 mm Hg indicates severe hypoxemia, which is a critical condition requiring immediate action to prevent tissue damage and organ failure. Normal PaO2 levels are around 80-100 mm Hg. A low PaO2 indicates poor oxygenation of the blood. Choice A (HCO3?2-) being slightly elevated is not an emergency but may indicate metabolic alkalosis. Choice B (SaO2) at 92% is within the normal range for most patients. Choice C (PaCO2) at 31 mm Hg is also within normal limits and suggests adequate ventilation. In summary, a low PaO2 level is the most critical finding that requires immediate intervention compared to the other choices.

Correct Answer: D

Rationale: Rationale: The correct answer is D. The BCG vaccine can cause a false-positive TB skin test result. Asking if the patient received the BCG vaccine is crucial to interpret the TB skin test accurately. If the patient received the BCG vaccine, the nurse should consider alternative diagnostic tests for TB. Incorrect choices: A: Asking about OTC medications is not directly related to the accuracy of the TB skin test. B: Family history of TB is important for assessing the patient's risk but does not impact the interpretation of the skin test. C: The duration of time since moving to the US may provide context but does not influence the TB skin test results.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates therapeutic communication by encouraging the client to express their thoughts and feelings. This approach helps the nurse understand the underlying reasons for the client's behavior and can lead to addressing issues such as anxiety or depression. Option A is incorrect as it doesn't address the client's emotional needs. Option B is incorrect as prescribing medication should not be the first response to social withdrawal. Option D is incorrect as it overlooks the importance of exploring the client's emotional state. Overall, option C is the best choice as it promotes open communication and a holistic approach to addressing the client's concerns.

Correct Answer: A

Rationale: The correct answer is A: Instruct the client to limit protein intake. Limiting protein intake is unnecessary for blood pressure control. Here's the rationale: 1. Sodium intake: Excessive salt intake can lead to high blood pressure, so teaching the client to avoid adding salt to foods is important. 2. Weight management: Excess weight can contribute to high blood pressure, so discussing weight reduction or maintenance is crucial. 3. Exercise: Regular physical activity can help lower blood pressure, making it important to stress the importance of an exercise program. 4. Protein intake: While a balanced diet is important for overall health, limiting protein intake specifically is not typically a key factor in blood pressure control.