What is the most important intervention when caring for a client with suspected pneumonia?

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.

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: 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: 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: A

Rationale: The correct answer is A because asking "Why haven't you taken your insulin?" may put the patient on the defensive. This question can come across as accusatory or judgmental, potentially making the patient feel guilty or defensive. It may hinder open communication and lead to a breakdown in the nurse-patient relationship. Explanation of other choices: B: While the question may be an attempt to gather information, it lacks sensitivity and may not promote open dialogue. C: Involving the patient's wife without the patient's consent may breach confidentiality and undermine the patient's autonomy. D: While asking the question may reveal reasons for the behavior, it is not the best approach as it can create a barrier to effective communication.

Correct Answer: D

Rationale: The correct answer is D: Administer morphine. The rationale is that vomiting after surgery can be a side effect of pain medication such as morphine. By administering morphine, the pain is reduced, which can help alleviate the vomiting. This intervention targets the root cause of the vomiting. Other choices are incorrect because: A: Administering antiemetics may help with nausea but does not address the underlying cause of vomiting. B: Placing the client in a supine position may worsen vomiting due to increased abdominal pressure. C: Encouraging deep breathing may help with relaxation but does not directly address the vomiting caused by pain.

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.

Correct Answer: D

Rationale: Rationale: 1. Altered family processes impact an infant's body image due to the emotional response and support provided by family members. 2. Positive family dynamics can help the infant cope with the diagnosis and build self-esteem. 3. Conversely, negative family processes may lead to feelings of inadequacy and affect body image. 4. Immobility, altered growth, and hemarthrosis are physical factors but do not directly influence body image. Summary: Altered family processes have the most significant impact on an infant's body image as they shape emotional support and self-perception. Immobility, altered growth, and hemarthrosis are important considerations but are not as directly related to body image in this context.

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.