Correct Answer: A

Rationale: Administering 50% dextrose IV push is the first priority in treating hypoglycemia to rapidly increase blood glucose levels. This choice is correct because in severe cases of hypoglycemia, when a client is admitted and unconscious or unable to swallow, intravenous administration of dextrose is crucial to quickly raise blood glucose levels. Option B, administering 15 grams of oral glucose, would be suitable for conscious clients with mild hypoglycemia who can swallow safely. Option C, rechecking blood glucose levels, should follow after immediate intervention to assess the response. Option D, administering a glucagon injection, is more suitable for cases where dextrose is not readily available or when the client does not respond to dextrose administration.

Correct Answer: A

Rationale: If a Korotkoff sound is heard immediately upon deflation, it may indicate an inaccurate reading. Waiting and palpating the systolic pressure can help confirm the accuracy of the measurement.
Choice A is the correct intervention because it allows the nurse to ensure the accuracy of the blood pressure reading.
Choice B is incorrect as increasing the inflation pressure is not necessary in this situation.
Choice C is also incorrect as switching to a larger cuff is not warranted based on the information provided.
Choice D is incorrect because documenting the finding as normal without further verification could lead to inaccurate information.

Correct Answer: B

Rationale: Obtaining a wound swab for culture and sensitivity is the most important intervention in this situation. It helps identify the presence of infection in the postoperative wound that could be causing the elevated temperature. By obtaining a wound swab, healthcare providers can determine the appropriate treatment needed to address any infection. Initiating contact isolation (
Choice
A) may be necessary in certain situations but is not the priority in this case. Assessing temperature (
Choice
C) is important but does not directly address the underlying cause of the elevated temperature. Using alcohol-based solutions for hand hygiene (
Choice
D) is a standard practice for infection control but is not the most crucial intervention in this scenario.

Correct Answer: A

Rationale: The correct action for the nurse to implement is to digitally check the client for a fecal impaction. In this scenario, the client's presentation of frequent small amounts of liquid stool after a period of no bowel movement suggests a possible impaction. By performing a digital examination, the nurse can assess for the presence of a blockage that may be causing the symptoms. Administering a laxative (
Choice
B) without assessing for impaction can worsen the situation. Increasing fluid intake (
Choice
C) is generally beneficial for bowel health but may not address the immediate issue of a potential impaction. Performing a digital rectal examination (
Choice
D) is similar to
Choice A but is more focused on assessing the rectum itself rather than checking for an impaction.

Correct Answer: C

Rationale: Maintaining a patent airway is crucial for clients with myasthenia gravis because muscle weakness can affect the muscles responsible for breathing, potentially leading to respiratory compromise. Encouraging rest, administering medication, and monitoring for respiratory infections are important aspects of care but do not take precedence over ensuring a patent airway for adequate oxygenation.