What is the most appropriate intervention for a client experiencing a heart attack?

Correct Answer: A

Rationale: Administering aspirin is the most appropriate intervention for a client experiencing a heart attack. Aspirin helps prevent blood clot formation, which is crucial in reducing further damage to the heart during a heart attack. It inhibits platelets from clumping together, improving blood flow to the heart muscle. Thrombolytics are used to dissolve existing blood clots, but aspirin is more preventive. Monitoring for arrhythmias is important but not the initial intervention. Administering morphine can be considered for pain relief but is not as crucial as administering aspirin to prevent further clot formation.

Correct Answer: C

Rationale: The correct answer is C because monitoring kidney function with regular laboratory tests is crucial in managing CKD. Regular testing helps identify changes in kidney function early, allowing for timely interventions to prevent complications. Administering diuretics (choice A) may worsen kidney function. Encouraging weight loss (choice B) may be necessary, but monitoring kidney function takes precedence. Encouraging the patient to limit fluid intake (choice D) may be necessary in some cases, but it is not the priority intervention.

Correct Answer: B

Rationale: The correct answer is B: Advise the patient to sleep with the head of the bed elevated. Elevating the head of the bed helps prevent stomach acid from flowing back into the esophagus during sleep, reducing GERD symptoms. This position also promotes better digestion. Choices A, C, and D are incorrect because encouraging large meals before bedtime can worsen GERD symptoms, drinking caffeinated beverages can trigger acid reflux, and avoiding antacids can lead to inadequate symptom management.

Correct Answer: C

Rationale: The correct answer is C: Pulmonary edema. In chronic heart failure, the heart cannot pump blood effectively, leading to fluid buildup in the lungs causing pulmonary edema. Monitoring for signs such as shortness of breath, wheezing, and crackles can help prevent respiratory distress. Incorrect choices: A: Hypoglycemia - Not directly related to chronic heart failure. B: Hyperkalemia - Can occur in heart failure but not a primary complication to monitor for. D: Anemia - Can be a consequence of chronic heart failure but not a primary complication to monitor for.

Correct Answer: C

Rationale: The correct answer is C: Critical thinking. Critical thinking involves analyzing information, evaluating options, and making sound decisions. When caring for multiple clients with complex care, critical thinking enables nurses to prioritize tasks, anticipate complications, and adapt care plans accordingly. Diagnostic reasoning (A) is important but focuses on identifying specific health issues. Physical assessment (B) is crucial but only addresses one aspect of care. Nursing care plans (D) are essential tools but rely on critical thinking for effective implementation. In conclusion, critical thinking is the key as it encompasses all aspects of problem-solving in complex care situations.

Correct Answer: B

Rationale: Correct Answer: B (Administer nonsteroidal anti-inflammatory drugs - NSAIDs) Rationale: 1. NSAIDs are commonly used for chronic pain management due to their anti-inflammatory properties. 2. NSAIDs target the underlying inflammation that often contributes to chronic pain. 3. Opioids may be reserved for severe pain due to their potential for addiction and side effects. 4. Monitoring blood pressure is important but not the primary intervention for chronic pain. 5. Acetaminophen is a mild pain reliever and may not be as effective for chronic pain compared to NSAIDs.

Correct Answer: B

Rationale: The correct answer is B: Encourage fluid intake. Adequate hydration helps in pain management by promoting circulation and reducing inflammation. Opioids (choice A) should only be used if non-pharmacological interventions fail. Administering oxygen (choice C) is not typically indicated for pain management. Monitoring electrolyte levels (choice D) is important but not the most immediate intervention for acute pain post-surgery.

Correct Answer: A

Rationale: The correct answer is A: Administer antihypertensive medication. In a hypertensive emergency, the priority is to lower blood pressure quickly to prevent organ damage. Antihypertensive medications like nitroprusside or labetalol are used for this purpose. Placing the client in a comfortable position and administering oxygen (B) may be beneficial, but lowering the blood pressure is the primary action. Monitoring blood pressure and administering antihypertensive medication (C) is correct, but the emphasis should be on immediate intervention. Monitoring the client's ECG (D) is important but not the primary action in a hypertensive emergency.

Correct Answer: B

Rationale: The correct answer is B: "Is there anything else you would like to mention?" This question allows the patient to share any additional information or concerns before concluding the interview. It shows empathy and ensures thorough communication. Choice A is not the best option as it may suggest the nurse is rushing or has overlooked something. Choice C is inappropriate as it lacks empathy and may make the patient feel rushed. Choice D is also incorrect as it shifts the focus to a different topic instead of allowing the patient to express any remaining issues or questions.