What is the first intervention for a client experiencing a myocardial infarction (MI)?

Correct Answer: D

Rationale: The correct answer is D: Administer morphine. Administering morphine is the first intervention for a client experiencing a myocardial infarction (MI) to help relieve pain and reduce anxiety. Oxygen may not be necessary if the client is not hypoxic. Administering aspirin is important but usually follows morphine. Monitoring ECG is crucial, but not the first intervention to address the immediate symptoms of MI.

Correct Answer: B

Rationale: The correct answer is B: increased fibrinogen. In DIC, there is consumption of coagulation factors leading to decreased fibrinogen levels. Heparin therapy helps by inhibiting further thrombus formation, allowing the body to replenish fibrinogen levels. Increased fibrinogen indicates a positive response. Incorrect choices: A) increased platelet count is not specific to Heparin therapy in DIC, C) decreased fibrin split products indicate ongoing coagulation, not a positive response, and D) decreased bleeding is a general response and not specific to Heparin therapy in DIC.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. When a client with asthma develops wheezing, the primary action is to administer bronchodilators to help dilate the airways and improve breathing. This helps relieve the symptoms of wheezing and prevent further complications. Providing pain relief (Choice B) is not the primary action for wheezing in asthma. Encouraging deep breathing (Choice C) may worsen the wheezing in an asthma attack. Performing chest physiotherapy (Choice D) is not the first-line treatment for wheezing in asthma.

Correct Answer: A

Rationale: The correct answer is A: Monitor urine output. This is the most important action because it helps assess the client's fluid status and kidney function. Monitoring urine output can indicate if the client's body is effectively eliminating excess fluid. Elevating the head of the bed (B) helps with respiratory function but is not the priority in fluid overload. Administering diuretics (C) may be necessary but should be based on urine output monitoring. Encouraging deep breathing (D) is important for respiratory function but not directly related to managing fluid overload.

Correct Answer: B

Rationale: Correct Answer: B - Administer oxygen Rationale: 1. Oxygen therapy is crucial in managing COPD exacerbation to improve oxygen saturation levels. 2. Adequate oxygenation is essential to prevent further respiratory distress and potential complications. 3. Oxygen therapy helps alleviate symptoms like shortness of breath and fatigue, improving overall comfort. 4. Monitoring oxygen saturation levels guides the effectiveness of treatment and ensures appropriate oxygen delivery. Summary: - Administering corticosteroids (A) may help reduce inflammation in COPD exacerbation but does not address the immediate need for oxygen. - Monitoring respiratory rate (C) is important but prioritizing oxygen administration is more critical for immediate respiratory support. - Administering diuretics (D) may be indicated in certain cases of COPD exacerbation with fluid retention but is not the priority over oxygen therapy.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. In the case of shock, the first priority is to restore circulating volume to improve tissue perfusion. IV fluids help increase blood volume and improve oxygen delivery to vital organs, addressing the underlying cause of shock. Choice B (Administer oxygen) can be important but is not the first priority. Choice C (Place the client in a supine position) may worsen certain types of shock. Choice D (Monitor blood pressure) is important but not the first action needed to address shock. Administering IV fluids promptly can stabilize the client's condition and prevent further deterioration.

Correct Answer: A

Rationale: The correct answer is A because health assessment helps establish a baseline database for comparison in future assessments, allowing for tracking of changes in health status over time. It provides essential information for identifying health issues and developing appropriate interventions. Choice B is incorrect as establishing rapport is a benefit but not the primary purpose. Choice C is incorrect as health assessment is typically conducted by primary healthcare providers, not specialists. Choice D is incorrect as quantifying pain is just one aspect of health assessment, not its primary purpose.

Correct Answer: D

Rationale: Step-by-step rationale for why answer D is correct: 1. Empathy and respect: By saying "I respect your decision to choose surgery," you acknowledge her autonomy and decision-making. 2. Supportive approach: This response shows understanding and non-judgmental support for her choice. 3. Person-centered care: Recognizing her individual needs and choices is crucial in providing quality healthcare. Summary: A: Irrelevant and insensitive to her medical needs. B: Disregards her current situation and overlooks the complexity of weight loss. C: Implies a one-size-fits-all approach without considering her specific circumstances. D: Demonstrates respect, understanding, and support for her decision-making.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. This is the most important intervention for a client with an obstructed airway because it helps to ensure that the patient is receiving adequate oxygen supply to prevent hypoxia. Oxygen therapy can help maintain oxygen saturation levels and support proper gas exchange in the lungs. Monitoring respiratory rate (B) is important but not as critical as ensuring oxygen supply. Administering morphine (C) is contraindicated as it can depress respiratory function further. Administering fluids (D) is not the priority in managing an obstructed airway.