Correct Answer: C

Rationale: A blood pressure of 88/52 mmHg indicates hypotension, which is a sign of worsening septic shock. Hypotension can lead to organ failure and requires immediate intervention. Elevated heart rate (choice
A), mild fever (choice
B), and slightly increased respiratory rate (choice
D) are common in septic shock and may not necessarily indicate a deteriorating condition as much as hypotension does.

Correct Answer: B

Rationale: A fever of 103 degrees Fahrenheit indicates that the infection is not under control despite antibiotic therapy. Fever is a common sign of ongoing infection or inadequate response to treatment. Nausea and vomiting, diffuse macular rash, and muscle tenderness are not typically indicative of the effectiveness of antibiotic therapy in treating infective endocarditis.

Correct Answer: A

Rationale: The correct first action when managing an acute exacerbation of asthma is to administer a bronchodilator as prescribed. Bronchodilators help open the airways and improve breathing in individuals experiencing an asthma exacerbation. Checking oxygen saturation (
Choice
B) is important but not the first action. Reassuring the client and encouraging deep breathing (
Choice
C) can be beneficial but should come after administering the bronchodilator. Providing emotional support to reduce anxiety (
Choice
D) is important but is not the initial priority in managing an acute exacerbation of asthma.

Correct Answer: B

Rationale: In this scenario, the nurse should first start an intravenous fluid bolus. This intervention is crucial in addressing severe dehydration associated with diabetic ketoacidosis, a life-threatening complication of type 1 diabetes. Administering intravenous insulin (
Choice
A) is important but should follow fluid resuscitation. Obtaining a blood glucose level (
Choice
C) is necessary but not as urgent as addressing the dehydration. Administering an antiemetic (
Choice
D) is not the priority in this situation.

Correct Answer: B

Rationale: The correct answer is B. Rifampin can cause red-orange discoloration of bodily fluids, including urine, saliva, and tears. This is a harmless side effect, but clients should be informed beforehand to prevent alarm.
Choice A is incorrect as orange-colored urine is not a sign of kidney dysfunction related to rifampin.
Choice C is incorrect because rifampin is more commonly associated with liver toxicity rather than kidney dysfunction.
Choice D is incorrect as vision changes are not a typical side effect of rifampin.