What is the most effective intervention for a client with shortness of breath and a history of heart failure?

Correct Answer: B

Rationale: The correct answer is B: Provide oxygen therapy. For a client with shortness of breath and a history of heart failure, oxygen therapy is the most effective intervention as it helps improve oxygenation and relieve respiratory distress. Administering diuretics may help manage fluid retention but does not directly address the breathing difficulty. Encouraging deep breathing may be beneficial for some respiratory conditions but may not be sufficient for a client with heart failure and shortness of breath. Applying oxygen therapy is similar to providing oxygen therapy and can help improve oxygen levels, but providing oxygen therapy is more specific and effective in this case.

Correct Answer: A

Rationale: The correct answer is A: Immobilize the spine. This is the most appropriate intervention for a client with a suspected spinal cord injury to prevent further damage. Immobilization helps stabilize the spine and reduce the risk of spinal cord compression or injury. Administering pain relief (B) or IV fluids (C) should only be done after proper spinal immobilization to avoid exacerbating the injury. Placing the client in a supine position (D) can be beneficial if done carefully after spine immobilization, but immobilizing the spine takes precedence to prevent any potential movement that could worsen the injury.

Correct Answer: D

Rationale: The correct answer is D - unexplained vaginal bleeding. This is a contraindication for hormone replacement therapy as it could indicate a serious underlying condition such as endometrial cancer. Hormone replacement therapy can increase the risk of endometrial cancer, so it should not be used in the presence of unexplained vaginal bleeding. A, B, and C are incorrect: A: Family history of stroke is not a direct contraindication for hormone replacement therapy. It may influence the decision-making process, but it is not a definitive contraindication. B: Ovaries removed before age 45 may actually be an indication for hormone replacement therapy to manage symptoms of menopause. C: Frequent hot flashes and/or night sweats are common symptoms of menopause and are not contraindications for hormone replacement therapy.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants help prevent the blood clot from getting larger and reduce the risk of it breaking loose and causing a pulmonary embolism. Other choices are incorrect because B: Monitoring vital signs alone does not treat the DVT, C: Providing bed rest can increase the risk of complications like pulmonary embolism, and D: Administering fibrinolytics is not the first-line treatment for DVT.

Correct Answer: D

Rationale: The correct answer is D: Encourage deep breathing. This is because encouraging deep breathing can help alleviate anxiety and promote relaxation, which can be beneficial in managing severe chest pain. Administering nitroglycerin (A) should only be done after assessing the client's condition and confirming it is safe to do so. Providing pain relief (B) may be necessary, but addressing the root cause of the pain should be the priority. Monitoring ECG (C) is important but should come after ensuring the client's immediate needs are addressed.

Correct Answer: D

Rationale: The correct answer is D: Urologist consult. This is the appropriate intervention for a client with suspected genitourinary trauma and visible blood at the urethral meatus because a urologist is an expert in diagnosing and managing issues related to the genitourinary system. They can perform a thorough evaluation, order appropriate tests (such as imaging studies), and provide the necessary treatment for any potential trauma. Option A (Insert a Foley catheter) could worsen the trauma if there is an underlying injury. Option B (In and out catheter specimen) and Option C (Voided urine specimen) focus on specimen collection and do not address the potential trauma, making them inappropriate interventions in this situation. Consulting a urologist ensures proper assessment and management of the suspected genitourinary trauma.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. This is the first step in the care of a client with acute chest pain because nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can relieve chest pain associated with angina or heart attack. Administering aspirin (choice B) is important as well, but nitroglycerin is prioritized due to its immediate effect in reducing chest pain. Administering opioids (choice C) and morphine (choice D) are not recommended as first-line treatments for acute chest pain, as they can mask symptoms and delay the diagnosis of potentially life-threatening conditions.

Correct Answer: D

Rationale: The correct answer is D. When a client refuses medication, the nurse should document the refusal for legal and communication purposes. Informing the healthcare provider ensures ongoing assessment and potential alternatives. Choice A lacks communication with the healthcare team. Choice B may not address the underlying issue. Choice C assumes alternative treatment is necessary without further evaluation.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. After a craniotomy, the client may experience decreased oxygen levels due to the surgical procedure, anesthesia, or potential complications. Administering oxygen helps ensure adequate oxygenation to the brain and tissues. Placing the client in a supine or Trendelenburg position can increase intracranial pressure, which is contraindicated post-craniotomy. Monitoring for arrhythmias is important, but ensuring oxygenation takes precedence as hypoxia can have immediate detrimental effects on brain function.