What is the most important intervention for a client with acute myocardial infarction (MI)?

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin is crucial for a client with acute MI as it helps prevent further blood clot formation by inhibiting platelet aggregation, reducing chances of additional cardiac events. Oxygen (B) is not routinely recommended unless hypoxemia is present. Morphine (C) can mask symptoms and delay treatment. Nitroglycerin (D) is used to relieve chest pain but may not be the most important intervention in acute MI. Administering aspirin promptly is vital to improve outcomes and reduce mortality in acute MI cases.

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating pneumonia caused by bacteria. They help to kill the bacteria causing the infection and prevent its spread. Administering fluids (B) is important for hydration but not the most crucial intervention. Monitoring temperature (C) is important but does not treat the root cause. Administering vaccines (D) may prevent certain types of pneumonia but is not the immediate intervention for an existing infection. Administering antibiotics promptly is vital to effectively treat pneumonia and prevent complications.

Correct Answer: A

Rationale: The correct answer is A because asking the patient to rate pain intensity using a scale (like 0-10) provides a standardized measure of pain perception. This quantitative data helps healthcare providers assess pain severity accurately and track changes over time. Asking about allergies (B) is important but not directly related to pain assessment. Asking the patient to describe the pain (C) provides qualitative information but may not be as reliable or consistent as a numerical rating. Measuring pain intensity using a scale (D) is similar to the correct answer but does not involve the patient's subjective input, which is crucial in pain assessment.

Correct Answer: C

Rationale: The correct answer is C: 12. At 18 months, a child should have 12 teeth, which include 8 incisors and 4 molars. This is because children typically start teething around 6 months, with the lower central incisors coming first. By 18 months, they should have all 8 incisors and usually the first set of molars. Options A, B, and D are incorrect because they do not align with the typical dental development timeline for children. Having only 6, 8, or 16 teeth at 18 months would indicate a delay or abnormality in dental growth.

Correct Answer: A

Rationale: The correct answer is A: Turn the client every two hours. This action helps prevent pressure ulcers by relieving pressure on specific areas of the body. Turning the client redistributes pressure, promotes circulation, and reduces the risk of tissue damage. It is a crucial part of pressure ulcer prevention in immobile or bedridden patients. Increasing protein intake (B) may aid in wound healing but does not directly prevent pressure ulcers. Encouraging rest (C) may not address the root cause of pressure ulcers. Applying dressings to wounds (D) is a treatment for existing ulcers, not prevention.

Correct Answer: D

Rationale: The correct answer is D because understanding the mother's pregnancy history can provide crucial insights into potential risk factors or exposures that could have contributed to the child's pneumonia. By knowing about the mother's smoking or drug use during pregnancy, the healthcare team can better assess the child's overall health and potential underlying conditions. Choice A is incorrect as it dismisses the importance of the question and fails to address the potential significance of the information. Choice B is incorrect as it downplays the relevance of the question, which is essential for gathering comprehensive information for the child's care. Choice C is incorrect as it makes an unsupported and potentially misleading statement about the direct cause of pneumonia without considering other factors.

Correct Answer: B

Rationale: The correct answer is B: Avoiding environmental allergens and smoking. Environmental allergens and smoking are common triggers for asthma attacks. Avoiding these triggers can significantly reduce the risk of exacerbations. Over-the-counter medications may provide symptomatic relief but do not address the underlying triggers. Increasing physical activity can be beneficial but may also trigger asthma attacks in some individuals. Limiting fluid intake to reduce mucus production is not a recommended strategy for managing asthma triggers.

Correct Answer: D

Rationale: The correct answer is D: Administer nitroglycerin. In acute pancreatitis, pancreatic inflammation can lead to pancreatic ischemia due to decreased blood flow. Nitroglycerin helps to dilate blood vessels and improve blood flow to the pancreas, reducing ischemia and potentially preventing further damage. Pain relief (choice A) may be necessary but does not address the underlying issue of ischemia. Administering fluids (choices B and C) is important but not the most critical intervention in this case. Administering nitroglycerin is the most crucial because it targets the root cause of pancreatic ischemia in acute pancreatitis.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In acute shortness of breath with COPD, oxygen therapy is crucial to improve oxygenation levels and alleviate respiratory distress. Oxygen can help reduce the workload on the lungs and heart. Antibiotics (B) are not indicated unless there is a suspected bacterial infection. Monitoring blood glucose (C) is important in diabetes management but not the priority in acute respiratory distress. Administering pain relief (D) may not address the underlying cause of the shortness of breath. Oxygen therapy directly targets the respiratory issue in COPD exacerbation, making it the most effective initial intervention.