A nurse is caring for a client with a myocardial infarction. The client questions the need for cardiac rehabilitation since "my heart is already damaged." Which of the following is the appropriate nursing response?
"Diet and exercise is good for you and good for your heart."
"It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it."
"Cardiac rehabilitation cannot undo the damage to your heart, but it can help you get back to your previous level of activity safely."
"Your doctor is the expert here, and I'm sure he would only recommend what is best for you."
The Correct Answer is C
Choice A reason: "Diet and exercise is good for you and good for your heart." This statement is true, but it is not the appropriate nursing response. It does not address the client's concerns or provide any specific information about cardiac rehabilitation. It may also sound dismissive or patronizing to the client.
Choice B reason: "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." This statement is empathetic, but it is not the appropriate nursing response. It does not explain the purpose or benefits of cardiac rehabilitation. It may also sound unrealistic or optimistic to the client.
Choice C reason: "Cardiac rehabilitation cannot undo the damage to your heart, but it can help you get back to your previous level of activity safely." This statement is the appropriate nursing response. It acknowledges the client's condition and provides factual information about cardiac rehabilitation. It also emphasizes the positive outcomes of cardiac rehabilitation, such as improving physical function, reducing symptoms, and preventing further complications.
Choice D reason: "Your doctor is the expert here, and I'm sure he would only recommend what is best for you." This statement is respectful, but it is not the appropriate nursing response. It does not answer the client's question or provide any education about cardiac rehabilitation. It may also sound evasive or deferential to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Fluconazole (Diflucan) is an antifungal medication that is used to treat infections caused by fungi, such as candidiasis, cryptococcosis, and histoplasmosis. It is not effective against anthrax, which is a bacterial infection caused by Bacillus anthracis.
Choice B reason: Ciprofloxacin (Cipro) is an antibiotic medication that belongs to the class of fluoroquinolones. It is used to treat various bacterial infections, including anthrax. It works by inhibiting the DNA synthesis of the bacteria and preventing them from multiplying. Ciprofloxacin is one of the recommended medications for post-exposure prophylaxis and treatment of anthrax, according to the Centers for Disease Control and Prevention (CDC).
Choice C reason: Varenicline (Chantix) is a medication that is used to help people quit smoking. It works by blocking the effects of nicotine on the brain and reducing the cravings and withdrawal symptoms. It has no role in the prevention or treatment of anthrax.
Choice D reason: Potassium iodide (KI) is a medication that is used to protect the thyroid gland from radioactive iodine in the event of a nuclear or radiological emergency. It works by saturating the thyroid with non-radioactive iodine and preventing it from absorbing radioactive iodine. It has no role in the prevention or treatment of anthrax.

Correct Answer is ["B","E"]
Explanation
Choice A reason: Continuing with the triage process is not an immediate intervention that needs to be taken by the triage nurse, as it may expose more people to the chemical hazard and worsen the situation. The triage nurse should stop the triage process and alert the emergency department staff and management about the potential contamination. The triage nurse should also follow the facility's emergency preparedness plan and protocols for dealing with chemical spills.
Choice B reason: Evacuating the emergency department is an immediate intervention that needs to be taken by the triage nurse, as it helps to protect the safety and health of the staff, clients, and visitors. The triage nurse should assist with evacuating everyone from the emergency department to a safe and designated area, away from the source of contamination. The triage nurse should also ensure that everyone is accounted for and that no one re-enters the emergency department until it is cleared by the authorities.
Choice C reason: Placing the client in a private room is not an immediate intervention that needs to be taken by the triage nurse, as it may not prevent the spread of contamination or provide adequate care to the client. The client who have been exposed to a chemical spill should not be moved to another area of the facility, as they may contaminate other people or surfaces along the way. The client should be kept in a separate and isolated area until they are decontaminated and assessed.
Choice D reason: Treating the client after contaminated items are removed is not an immediate intervention that needs to be taken by the triage nurse, as it may delay or compromise the care of the client. The client who has been exposed to a chemical spill should be treated as soon as possible, as some chemicals can cause serious or irreversible damage to the skin, eyes, lungs, or other organs. The triage nurse should provide basic life support measures, such as airway management, oxygen therapy, or bleeding control while wearing appropriate personal protective equipment (PPE). The triage nurse should also remove any contaminated clothing or jewelry from the client and place them in a sealed bag.
Choice E reason: Sending the client and EMS crew to decontamination is an immediate intervention that needs to be taken by the triage nurse, as it helps to remove or neutralize any harmful chemicals from their skin, hair, or clothing. The triage nurse should direct or escort the client and EMS crew to a designated decontamination area or unit, where they will undergo a thorough washing process with water and soap or other solutions. The triage nurse should also monitor their vital signs and symptoms during and after decontamination.
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