Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin helps prevent further clot formation by inhibiting platelet aggregation, reducing the risk of additional heart damage. It is a standard treatment in acute myocardial infarction. Administering morphine (B) may be considered for pain relief but is not the primary intervention. Monitoring vital signs (C) is important, but not the primary intervention. Administering fibrinolytics (D) is indicated in certain cases but is not the primary intervention and requires specific criteria and caution.

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: B

Rationale: The correct answer is B: a set of rules. Novice nurses rely on established guidelines and protocols to make decisions as they lack the experience to rely solely on intuition or journal articles. Rules provide structure and consistency in decision-making, reducing the margin of error. Intuition (choice A) may not be reliable without prior experience. Journal articles (choice C) can be overwhelming and may not directly apply to the specific situation. Advice from supervisors (choice D) can be helpful but may not always be readily available, and it's important for novice nurses to develop their own decision-making skills.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. When a client presents with symptoms of hypoglycemia, the nurse should prioritize raising the blood sugar levels immediately to prevent further complications. Administering glucose helps to quickly address the low blood sugar levels and alleviate symptoms. Monitoring blood glucose (B) is important but not the first step in an acute situation. Administering insulin (C) would worsen hypoglycemia. Monitoring for arrhythmias (D) is not the primary concern when dealing with hypoglycemia.

Correct Answer: C

Rationale: The correct answer is C: Pulmonary edema. In chronic heart failure, the heart cannot pump blood effectively, leading to fluid buildup in the lungs causing pulmonary edema. Monitoring for signs such as shortness of breath, wheezing, and crackles can help prevent respiratory distress. Incorrect choices: A: Hypoglycemia - Not directly related to chronic heart failure. B: Hyperkalemia - Can occur in heart failure but not a primary complication to monitor for. D: Anemia - Can be a consequence of chronic heart failure but not a primary complication to monitor for.