A client who has Type 1 diabetes and is at 10-weeks gestation comes to the prenatal clinic complaining of a headache, nausea, sweating, feeling shaky, and being tired all the time. What action should the nurse take first?

Correct Answer: A

Rationale: The correct answer is A: Check the blood glucose level. This is the first action the nurse should take because the client is presenting with symptoms of hypoglycemia, which can be life-threatening for a pregnant woman with Type 1 diabetes. By checking the blood glucose level, the nurse can determine if the client's symptoms are due to low blood sugar levels and take appropriate action. Drawing blood for a Hemoglobin A1C (choice B) is not the first priority in this acute situation. Assessing urine for ketone levels (choice C) is important in managing diabetes but is not the priority when the client is showing signs of hypoglycemia. Providing the client with a protein snack (choice D) may help raise blood sugar levels, but checking the blood glucose level is essential to determine the appropriate intervention.

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.

Correct Answer: D

Rationale: The correct answer is D: Monitor the client's intravenous site hourly during the treatment. This is crucial to reduce the risk of vesicant extravasation, which can cause tissue damage if the chemotherapy leaks into the surrounding tissues. By monitoring the IV site hourly, the healthcare provider can detect any signs of infiltration or extravasation early and take necessary actions to prevent further harm. A: Administering an antiemetic before starting chemotherapy is unrelated to preventing vesicant extravasation. B: Instructing the client to drink plenty of fluids does not directly address the risk of vesicant extravasation. C: Keeping the head of the bed elevated is not specific to preventing vesicant extravasation and may not effectively reduce the risk.