A male client in the day room becomes increasingly angry and aggressive when denied a day-pass. Which action should the nurse implement?

Correct Answer: D

Rationale: The correct answer is D because instructing the client to sit down and be quiet is a non-confrontational and calming approach to de-escalate the situation. It helps redirect the client's focus and encourages self-regulation. Choice A may reinforce the aggressive behavior by rewarding it. Choice B (putting behavior on extinction) may escalate the situation further. Choice C (decreasing TV volume) does not address the client's behavior directly.

Correct Answer: B

Rationale: The correct answer is B because the client delivered a 7-pound infant 12 hours ago and is now experiencing a severe headache, which could indicate postpartum preeclampsia. Checking if the client received anesthesia during delivery is crucial as certain types of anesthesia can increase the risk of postpartum preeclampsia. This step is important to determine if anesthesia is a contributing factor to the client's symptoms. Option A is incorrect because immediate action is needed to address the client's symptoms related to anesthesia. Option C is incorrect as reassessing vital signs alone may not provide information specific to the client's headache. Option D is incorrect as obtaining a hemoglobin and hematocrit would not directly address the client's headache or potential anesthesia-related issues.

Correct Answer: A

Rationale: The correct answer is A because the OB nurse's background in obstetrics makes them most suitable to care for a post-operative patient with an IV. This assignment aligns with the nurse's skill set and ensures safe and competent care. Choices B, C, and D involve medical-surgical conditions that may require specialized knowledge and skills beyond the OB nurse's expertise, potentially compromising patient care. Assigning the OB nurse to care for a post-operative patient with an IV is the most appropriate choice given the circumstances.

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: B

Rationale: The correct answer is B because increased thirst and drinking more fluids than usual is a common symptom of diabetes mellitus due to high blood sugar levels causing dehydration. Refusing to eat favorite meals (choice A) is not a typical symptom. Voids only one or two times per day (choice C) is more related to urinary issues than diabetes. Gaining 10 pounds within one month (choice D) is not a specific symptom of diabetes and can be attributed to various factors.

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: C

Rationale: The correct answer is C, increased serum creatinine level. In CHF, the heart's reduced pumping ability can lead to decreased blood flow to the kidneys, resulting in impaired kidney function. This can cause an elevation in serum creatinine level, indicating decreased kidney function. Elevated serum sodium level (A) is not typically seen in CHF, as patients often have fluid retention leading to dilutional hyponatremia. Decreased BNP level (B) is not expected in CHF, as BNP is released in response to increased ventricular stretching and volume overload. Elevated hemoglobin and hematocrit levels (D) are not directly related to CHF; they may be seen in conditions like dehydration or chronic hypoxia, but not specifically in CHF.

Correct Answer: C

Rationale: The correct answer is C: Place the client in Trendelenburg position. This is the first action to take in a client with suspected air embolism, a potential complication of central line insertion. Placing the client in Trendelenburg position with the head down and the legs elevated can help prevent air from reaching the heart and lungs. This action can help stabilize the client's condition before further interventions can be implemented. Stopping the TPN infusion (choice A) can be important, but the priority in this situation is to address the potential air embolism. Notifying the healthcare provider (choice B) can be done after the immediate intervention. Administering oxygen (choice D) is important, but placing the client in Trendelenburg position takes precedence in this emergency situation.