Correct Answer: B

Rationale: The correct answer is B: "Is there anything else you would like to mention?" This question allows the patient to share any additional information or concerns before concluding the interview. It shows empathy and ensures thorough communication.


Choice A is not the best option as it may suggest the nurse is rushing or has overlooked something.
Choice C is inappropriate as it lacks empathy and may make the patient feel rushed.
Choice D is also incorrect as it shifts the focus to a different topic instead of allowing the patient to express any remaining issues or questions.

Correct Answer: A

Rationale: The correct answer is A: Administer antihypertensive medication. In a hypertensive emergency, the priority is to lower blood pressure quickly to prevent organ damage. Antihypertensive medications like nitroprusside or labetalol are used for this purpose. Placing the client in a comfortable position and administering oxygen (
B) may be beneficial, but lowering the blood pressure is the primary action. Monitoring blood pressure and administering antihypertensive medication (
C) is correct, but the emphasis should be on immediate intervention. Monitoring the client's ECG (
D) is important but not the primary action in a hypertensive emergency.

Correct Answer: A

Rationale: The correct answer is A because it focuses on prioritizing the assessment by first addressing the immediate problem of shortness of breath. By examining only the body areas related to the current issue, the nurse can quickly gather essential information to manage the patient's respiratory distress effectively. Once the critical issue is stabilized, a complete assessment can be conducted to identify any underlying problems or potential complications. This approach ensures that the nurse addresses the most urgent needs first before proceeding to a comprehensive assessment.


Choice B is incorrect because it suggests only examining body areas directly related to the hospitalization problem, which may overlook other critical issues contributing to the shortness of breath.
Choice C is incorrect as shortness of breath is not a normal finding and should not be dismissed without further evaluation.
Choice D is incorrect as examining the entire body without focusing on the immediate issue may delay appropriate interventions for the patient's respiratory distress.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. The initial priority in managing sepsis is to restore perfusion and oxygenation by giving IV fluids to support blood pressure and organ perfusion. This helps to improve tissue oxygenation and prevents further organ damage. Administering insulin (choice
B) is not the priority in the initial management of sepsis. Monitoring blood pressure (choice
C) is important but not the first step in the management of sepsis. Administering insulin is also listed twice and is not relevant to the immediate management of sepsis.

Correct Answer: C

Rationale: The primary purpose of an abdominal binder after surgery is to increase circulation. An abdominal binder helps improve blood flow to the surgical site, which can aid in reducing swelling, promoting healing, and preventing complications such as blood clots. It provides gentle compression to support the abdominal muscles and tissues without restricting circulation.


Choice A (Promote comfort) is incorrect because while an abdominal binder may provide some comfort by supporting the abdomen, its primary purpose is not solely for comfort.


Choice B (Prevent infection) is incorrect because an abdominal binder does not directly prevent infection. Infection prevention is primarily achieved through proper wound care and infection control practices.


Choice D (Provide wound care) is incorrect because an abdominal binder does not provide wound care. Wound care involves cleaning, dressing changes, and monitoring for signs of infection, which are separate from the purpose of an abdominal binder.