What is the best approach to assist a client in performing self-care after an acute myocardial infarction, when the client expresses concern about fatigue?

Correct Answer: B

Rationale: The best approach to assist a client in performing self-care after an acute myocardial infarction, especially when the client expresses concern about fatigue, is to gradually resume self-care tasks while focusing on rest periods. This approach allows the client to build confidence in managing their self-care activities while also addressing the issue of fatigue. Choice A is incorrect as it focuses on asking for assistance rather than promoting self-care. Choice C is inappropriate as it suggests delegating the client's self-care tasks to assistive personnel instead of empowering the client. Choice D is incorrect as it can lead to deconditioning and is not conducive to the client's recovery process.

Correct Answer: B

Rationale: The correct answer is to keep the head of the bed at 30 degrees. This position helps reduce the risk of aspiration and improves ventilation. Suctioning the airway every hour may lead to mucosal damage and increase the risk of infection. Changing the ventilator tubing every day is not necessary unless there are specific indications to do so, as it can increase the risk of contamination and infection. Administering a bronchodilator every 2 hours is not a standard practice and should be done based on the client's individualized treatment plan.

Correct Answer: D

Rationale: The correct answer is D: Oxygen saturation. The priority assessment in this situation is oxygen saturation because postoperative clients are at risk for respiratory complications, such as hypoxia due to factors like anesthesia effects, impaired lung function, or pain interfering with deep breathing. Monitoring oxygen saturation is crucial to detect any respiratory compromise early. Capillary refill, bowel sounds, and temperature are important assessments but are not the priority in this immediate postoperative period.

Correct Answer: A

Rationale: The correct answer is A: 'Place your baby's crib away from heat vents.' Placing the crib away from heat vents is essential to prevent the baby from becoming overheated and to reduce the risk of Sudden Infant Death Syndrome (SIDS). Choice B is incorrect because placing the crib close to a heater increases the risk of overheating and poses a fire hazard. Choice C is incorrect as placing the crib near a window exposes the baby to drafts and temperature fluctuations. Choice D is incorrect as soft toys in the crib can pose a suffocation risk to the newborn.

Correct Answer: B

Rationale: Acetylcysteine is the antidote for acetaminophen overdose. It works by replenishing glutathione, a key component in detoxifying acetaminophen metabolites, thus preventing liver damage. Naloxone is used to reverse opioid overdose, not acetaminophen. Flumazenil is a benzodiazepine antidote. Activated charcoal is used to limit absorption in cases of poisoning, but it is not the antidote for acetaminophen overdose.

Correct Answer: A

Rationale: Correct Answer: Increasing the client's oxygen flow rate should be the nurse's first action. Hypoxia is a common complication of pneumonia and can lead to confusion. Providing adequate oxygenation is essential in addressing hypoxia and improving the client's condition.\nOption B: Obtaining vital signs is important but addressing hypoxia takes precedence in the setting of new onset confusion.\nOption C: Administering an antibiotic is important for treating pneumonia but addressing hypoxia and confusion is the priority.\nOption D: Notifying the provider may be necessary but addressing the immediate physiological need of oxygenation should come first.

Correct Answer: A

Rationale: During a seizure, the most appropriate action for a healthcare provider is to protect the patient's head. This helps prevent injury, especially considering the involuntary movements and potential thrashing associated with seizures. Restraint should be avoided as it can lead to further injury or distress for the patient. Inserting an airway is not recommended during an active seizure as the patient's airway may not be obstructed, and it could pose a risk of injury. Giving the patient water during a seizure is also not advisable as there is a risk of aspiration. Therefore, the priority is to ensure the patient's safety by protecting their head.

Correct Answer: B

Rationale: Increased appetite may indicate that the client is experiencing symptoms of hyperthyroidism due to an excessive dose of levothyroxine. This finding suggests a need for a dosage adjustment to prevent potential complications. Tremors are more commonly associated with hyperthyroidism, not necessarily indicating a need for dosage adjustment. Bradycardia and diarrhea are not typical signs of an incorrect levothyroxine dosage and would not directly warrant a need for adjustment.

Correct Answer: B

Rationale: The correct answer is B: 'Monitor the client's weight daily.' In clients with heart failure on fluid restriction, monitoring daily weight is crucial to track fluid balance. This allows healthcare providers to assess if the client is retaining excess fluid, a common issue in heart failure. Choices A, C, and D are incorrect. Encouraging the client to drink more water contradicts the fluid restriction; avoiding drinking water after 6 PM is not specific to managing fluid restriction; and monitoring fluid intake only during meals does not provide a comprehensive assessment of fluid balance throughout the day.