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: D

Rationale: The correct answer is D: unexplained vaginal bleeding. This is a contraindication for hormone replacement therapy as it may indicate underlying conditions that need to be addressed before starting hormone therapy to avoid potential risks. Vaginal bleeding could be a sign of endometrial hyperplasia or cancer, which can be exacerbated by hormone therapy. Choices A, B, and C are not contraindications for hormone replacement therapy. Family history of stroke may influence the choice of therapy but not necessarily contraindicate it. Ovaries removed before age 45 and frequent hot flashes/night sweats are common indications for hormone replacement therapy to alleviate symptoms of menopause.

Correct Answer: C

Rationale: The correct answer is C: Limit phosphorus and potassium intake. Patients with chronic kidney disease often have difficulty excreting phosphorus and potassium, leading to potential complications. Limiting phosphorus and potassium intake can help prevent further kidney damage and maintain electrolyte balance. Prioritizing this dietary recommendation is crucial for managing the progression of the disease. Incorrect choices: A: Increasing protein intake can put additional strain on the kidneys and may lead to further deterioration of kidney function. B: Increasing potassium intake can be dangerous for patients with chronic kidney disease as they may have difficulty regulating potassium levels. D: Decreasing fluid intake may be necessary in some cases, but it is not the priority in terms of managing chronic kidney disease.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. This intervention is crucial for a client with an obstructed airway as it helps maintain oxygenation while efforts are made to clear the obstruction. Oxygen administration ensures the client receives adequate oxygen supply to prevent hypoxia and further complications. Monitoring respiratory rate (B) is important but not the priority when airway obstruction is present. Applying a cold compress (C) or administering corticosteroids (D) are not appropriate interventions for an obstructed airway and do not address the immediate need for adequate oxygenation.

Correct Answer: C

Rationale: Rationale: The correct answer is C: "How long have you been feeling this way?" This question is essential to differentiate between dysthymic disorder and major depressive disorder. In dysthymic disorder, symptoms persist for at least 2 years, whereas in major depressive disorder, symptoms typically last for at least 2 weeks. By asking how long the patient has been feeling this way, the nurse can determine the duration of the symptoms and make a more accurate diagnosis. Summary of other choices: A: "Has there been any change in your weight?" This question is more relevant to assessing changes in appetite, which can be a symptom of depression, but it does not differentiate between dysthymic and major depressive disorders. B: "Are you having any thoughts of suicide?" While important to assess for safety, this question does not help differentiate between the two disorders. D: "Are you having feelings of worthlessness?" This question is relevant to assessing symptoms of depression but does not

Correct Answer: B

Rationale: The correct answer is B: Administer pain relief. The first priority for a client with an open wound is to manage their pain to ensure their comfort and well-being. Pain relief helps the client relax, reduces stress, and promotes healing. Cleaning and dressing the wound, administering anticoagulants, and monitoring blood pressure are important tasks but are secondary to addressing the client's immediate pain and discomfort. Pain relief should be the initial focus to ensure the client's overall care and recovery.

Correct Answer: A

Rationale: The correct answer is A because a comprehensive assessment involves gathering a complete health history and conducting a thorough physical examination to evaluate the client's overall health status. This includes assessing past medical history, family history, current medications, lifestyle factors, and performing a head-to-toe physical examination. This holistic approach helps in identifying any potential health issues or risk factors. Choice B is incorrect because a specific focus on a body system is not comprehensive and may miss other important aspects of the client's health. Choice C is incorrect as emergency triage is a rapid assessment to determine the severity of a medical condition and prioritize treatment, not a comprehensive assessment. Choice D is incorrect because a specific assessment of client complaints is focused only on the reported issues and may not provide a comprehensive overview of the client's health.

Correct Answer: C

Rationale: The correct answer is C: Jaundice. In chronic liver disease, the liver's ability to process bilirubin is impaired, leading to jaundice. This is characterized by a yellowing of the skin and eyes. Monitoring for jaundice is crucial as it indicates liver dysfunction. Hypoglycemia (A) is not a typical complication of chronic liver disease. Hyperkalemia (B) is more commonly associated with kidney dysfunction. Anemia (D) can occur in liver disease but is not as specific a complication as jaundice. Therefore, monitoring for jaundice in a patient with chronic liver disease is essential for early detection and management of liver dysfunction.

Correct Answer: A

Rationale: The correct answer is A: Administer IV antibiotics. Administering IV antibiotics is crucial in treating pneumonia as it helps combat the underlying bacterial infection causing pneumonia. Prompt antibiotic therapy can prevent complications and improve patient outcomes. Administering pain medications (B) may help manage symptoms but does not address the root cause. Administering antiemetics (C) may help with nausea and vomiting but does not directly treat pneumonia. Option D is similar to the correct answer but lacks the specificity of IV antibiotics, which are often preferred for severe cases.