A 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to ICU are, BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are, PAWP 1, PAP 8/2, RAP -1, SVR 1600. What nursing action has the highest priority?

Correct Answer: B

Rationale: The correct answer is B: Increase the client's IV fluid rate to 200 ml/hr. The client's vital signs indicate hypotension, tachycardia, decreased urine output, and cool skin, suggesting hypovolemic shock. Increasing IV fluid rate will help to restore intravascular volume and improve perfusion to vital organs. This is the highest priority as it addresses the immediate physiological need for circulatory support. Choice A is incorrect because hypothermia is not indicated based on the client's presentation. Choice C is incorrect as it does not address the client's urgent physiological needs. Choice D is incorrect as drawing blood cultures, while important, is not the most immediate priority in this situation.

Correct Answer: C

Rationale: The correct answer is C: Place the client in Trendelenburg. This position helps alleviate pressure on the umbilical cord, preventing compression and improving blood flow to the fetus. It is crucial to prioritize this action to prevent fetal distress or compromise. Administering oxygen (A) is important, but not the initial priority. Notifying the operating room team (B) may be necessary but is not the immediate action. Administering a fluid bolus (D) is not indicated in this situation. Placing the client in Trendelenburg is the most appropriate and urgent action to ensure the safety and well-being of the fetus.

Correct Answer: A

Rationale: The correct answer is A: Weigh the child daily. Daily weight monitoring is the most accurate way to determine fluid retention in a child with nephrotic syndrome as it provides real-time data on fluid status. Weight gain is a key indicator of fluid retention in these patients. Observing lower extremities for pitting edema (B) is subjective and may not accurately reflect fluid status. Measuring abdominal girth weekly (C) may not provide timely information on fluid retention. Weighing wet diapers (D) does not give a comprehensive picture of total fluid retention and may not be as accurate as daily weight monitoring.

Correct Answer: D

Rationale: The correct answer is D: Do not expose other children. RSV is very contagious even without direct oral contact. Rationale: RSV is highly contagious and can spread through respiratory droplets, making it important to prevent exposing other children to the virus. Even without direct oral contact, the virus can be transmitted. Therefore, it is crucial to avoid putting other children at risk of contracting RSV. Summary of other choices: A: Wearing a mask may not be practical for an infant and may not provide sufficient protection against RSV transmission. B: RSV can still be contagious for several days after symptoms appear, so the child may still be able to spread the virus. C: While avoiding infants under 6 months can be a good precaution, all children should be protected from exposure to RSV due to its high contagiousness.

Correct Answer: A

Rationale: The correct answer is A: Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours. In a patient with urinary sepsis, timely administration of antibiotics is crucial to prevent further complications. Piperacillin/tazobactam is a broad-spectrum antibiotic effective against a wide range of bacteria commonly involved in sepsis. Administering it first ensures prompt initiation of treatment. Other choices (B) Vancomycin, (C) Pantoprazole, and (D) Enoxaparin are important medications but are not as time-sensitive in this scenario. Vancomycin and Enoxaparin have longer administration times, and Pantoprazole is a maintenance medication that is not urgent in the acute management of sepsis.