Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse’s next action?

Correct Answer: A

Rationale: The correct answer is A: Call for help and note the time. This is the priority action because the client is unresponsive after a myocardial infarction, indicating a potential emergency situation. Calling for help ensures timely assistance and activates the emergency response team. Noting the time is crucial for accurate documentation and helps in determining the duration of unresponsiveness. Clearing the airway (B) and giving thumps to the precordium (C) are not appropriate without confirming the client's condition first. Checking the pulse (D) can be done after calling for help.

Correct Answer: B

Rationale: Correct Answer: B - Kinked or obstructed chest tube. Rationale: 1. Tension pneumothorax is a life-threatening condition where air accumulates in the pleural space, causing lung collapse. 2. Signs include respiratory distress, chest pain, hypoxia, and tracheal deviation. 3. Nurse Amanda must check the chest tube for kinks or obstructions as it can prevent proper drainage and exacerbate the condition. 4. Infection of the lung (A) may be a concern but is not immediate in tension pneumothorax. 5. Excessive water in the water-seal chamber (C) may indicate a leak but is not directly related to tension pneumothorax. 6. Excessive chest tube drainage (D) may be expected initially, but if it suddenly stops, it could indicate kinking or obstruction.

Correct Answer: A

Rationale: The correct initial response is A: Explain the risks of not having the surgery. This is crucial to ensure the client fully understands the consequences of refusing the surgery. It allows the nurse to address any concerns or misconceptions the client may have, enabling an informed decision-making process. Notifying the physician immediately (B) may be necessary but should follow after attempting to provide education. Notifying the nursing supervisor (C) is not the priority in this situation. Recording the client’s refusal in the nurses’ notes (D) is important but should not be the first action taken.

Correct Answer: D

Rationale: The correct answer is D: Counselor. The nurse assumes the role of counselor when guiding a client in making healthcare decisions by providing emotional support, helping the client explore options, and facilitating informed decision-making. A leader typically involves taking charge or directing a group, which may not always be appropriate in this context. An advocate focuses on promoting the client's rights and best interests but may not necessarily provide the counseling aspect. A liaison acts as a link or intermediary between the client and other healthcare providers, which is different from providing direct counseling and support.

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. The cuff size should be appropriate to ensure accurate readings. 2. A cuff that is too small can result in falsely elevated readings. 3. A cuff that is too large can lead to falsely low readings. 4. Placing the cuff 1 cm above the brachial artery ensures proper placement for accurate measurements. Other Choices: A: The nurse should make sure that the cuff is deflated fully - Incorrect. The cuff should be inflated fully for accurate readings. B: then immediately start the second reading for the same client - Incorrect. It is important to wait a few minutes between readings to allow the blood vessels to recover. C: The nurse should release the valve carefully so that the pressure decreases at the rate of 2-3 mmHg per second - Incorrect. The pressure should be released at a steady rate, not specific to 2-3 mmHg per second.