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: A

Rationale: The correct answer is A because using the defrost setting on microwave ovens can help safely heat breast milk or formula for the infant without compromising its quality. This method ensures that the milk is heated evenly and prevents hot spots that could burn the baby's mouth. Choice B is incorrect because refrigerating partially used bottles can lead to bacterial growth and contamination. Choice C is incorrect as mixing water and concentrate in different ratios can result in either too diluted or too concentrated formula, which can be harmful to the infant. Choice D is incorrect as adding new formula to partially used bottles can also lead to bacterial growth and spoilage.

Correct Answer: C

Rationale: The correct answer is C: Severity. In the PQRSTU mnemonic, "S" stands for Severity, which refers to the intensity or seriousness of the symptoms experienced by the patient. This is crucial in assessing the impact of the problem on the patient's health and well-being. Incorrect choices: A: Swelling - Swelling is a physical symptom and does not encompass all aspects of the patient's perception. B: Subjectivity - While the patient's subjective experience is important, it does not specifically refer to severity. D: Symptoms - While symptoms are part of the patient's perception, the "S" in PQRSTU specifically focuses on the severity of those symptoms.

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. Washing hands before and after cord care is a standard hygiene practice to prevent infection. 2. Options A and B are incorrect as alcohol and covering the cord can lead to complications. 3. Option C suggests recognizing concerning changes in the cord, indicating good understanding. 4. Thus, option D is correct as it is a crucial step in cord care and does not indicate a need for further teaching.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. In severe allergic reactions, such as anaphylaxis, epinephrine is the first-line treatment as it rapidly reverses life-threatening symptoms like airway constriction and low blood pressure. Antihistamines (choice B) may help with mild symptoms but are not sufficient for severe reactions. Applying a cold compress (choice C) is not effective in treating anaphylaxis. Encouraging deep breathing (choice D) is not appropriate as the client may have difficulty breathing due to airway constriction. Administering epinephrine is crucial to quickly stabilize the client's condition in a severe allergic reaction.

Correct Answer: D

Rationale: The correct answer is D: provide culturally sensitive and appropriate care. Including cultural information in the health assessment helps healthcare providers understand the patient's beliefs, practices, and preferences, allowing for tailored care that respects the patient's cultural background. This improves communication, trust, and overall health outcomes. Choice A is incorrect because cultural information does not necessarily identify the cause of an illness. Choice B is incorrect as it overemphasizes diagnosis without considering the patient's cultural context. Choice C is incorrect as it does not directly address the importance of cultural information in healthcare.

Correct Answer: D

Rationale: I must correct you on this question. The correct answer for the most appropriate action for a nurse to take when a client develops a deep vein thrombosis (DVT) is not D. The correct answer should be C: Provide anticoagulant therapy. Anticoagulant therapy is the standard treatment for DVT to prevent the blood clot from getting larger and to reduce the risk of it breaking loose and causing a pulmonary embolism. Elevating the leg and applying compression can help with symptoms but are not the primary treatment for DVT. Massage is contraindicated as it can dislodge the blood clot.

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: A

Rationale: The correct answer is A - Administer IV fluids. This is the priority intervention for a client with suspected hypovolemia and hypotension as it helps to restore intravascular volume and improve blood pressure. IV fluids will address the underlying cause of hypotension by increasing circulating volume. Monitoring blood pressure (B) is important but administering IV fluids takes precedence. Administering corticosteroids (C) is not indicated for hypovolemia and hypotension. Administering oxygen (D) may be necessary if there is evidence of hypoxia, but addressing fluid volume status is the primary concern in this scenario.