A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: The correct action the nurse should take when caring for a client experiencing acute alcohol withdrawal is to administer lorazepam as prescribed. Lorazepam is a benzodiazepine used to prevent seizures and manage agitation in clients undergoing alcohol withdrawal. Administering haloperidol (Choice A) is not recommended in alcohol withdrawal as it may lower the seizure threshold. Keeping the client in a supine position (Choice B) is not specifically indicated in managing alcohol withdrawal. Encouraging the client to drink fluids with meals (Choice D) is important for hydration but does not address the acute symptoms of alcohol withdrawal.

Correct Answer: B

Rationale: When administering enoxaparin, it is important to pinch the skin to ensure proper subcutaneous injection. Massaging the injection site after administering the medication is not recommended. Administering the medication at bedtime is not a specific requirement for enoxaparin. Aspirating before injecting the medication is not necessary for subcutaneous injections like enoxaparin.

Correct Answer: B

Rationale: The correct answer is B. A high PaCO2 level (55 mm Hg) in a client with chronic emphysema suggests respiratory acidosis, which requires further treatment. In chronic emphysema, impaired gas exchange leads to elevated carbon dioxide levels in the blood. Option A (PaO2 level of 89 mm Hg) is near the normal range and does not indicate immediate treatment. Option C (HCO3 level of 25 mEq/L) and option D (pH level of 7.37) are within normal limits and do not suggest the need for further treatment in this context.

Correct Answer: C

Rationale: In a patient with a history of angina experiencing chest pain, the priority action for the nurse is to obtain a 12-lead ECG. This helps in assessing for myocardial infarction, a serious condition that requires immediate attention. Administering oxygen, nitroglycerin, or notifying the healthcare provider can be important interventions but obtaining the ECG comes first to determine the presence of myocardial infarction and guide further management.

Correct Answer: A

Rationale: The correct answer is A: Wear loose clothing over the radiation site. Clients receiving radiation therapy should wear loose clothing over the treatment area to prevent irritation and promote healing. Choice B is incorrect as scented lotions can irritate the skin during radiation therapy. Choice C is incorrect because ice packs should not be applied to the radiation site as they can exacerbate skin reactions. Choice D is incorrect as exposing the radiation site to sunlight can increase skin damage and should be avoided.

Correct Answer: B

Rationale: The correct answer is B. An elevated creatinine level, such as 1.8, suggests potential kidney dysfunction, requiring further assessment. Sodium level within normal limits (135-145 mEq/L), hemoglobin level of 15 g/dL, and potassium level of 4.2 mEq/L are all within normal ranges and do not indicate immediate concerns. Therefore, they do not require further evaluation at this time.

Correct Answer: C

Rationale: Changing the entire pouching system weekly is essential for maintaining skin integrity and preventing infection. Option A is incorrect as applying a skin barrier should be done during the pouch change, not separately. Option B is incorrect as ileostomy pouches should be emptied when they are one-third to one-half full to prevent leakage. Option D is incorrect because cleansing the peristomal skin with alcohol can be too harsh and may cause skin irritation.

Correct Answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical and priority intervention in such cases as it aims to increase oxygen levels in the blood. Administering bronchodilators may be beneficial for specific respiratory conditions like asthma or COPD, but oxygen should be the initial priority. Administering IV fluids and providing humidified air, while important in certain situations, are not the primary interventions for respiratory distress.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Administering anticoagulants is the most appropriate nursing intervention for a patient with suspected DVT because it helps prevent further clot formation and complications. Applying compression stockings (choice B) can be a preventive measure but is not the primary intervention for treating DVT. Encouraging ambulation (choice C) is beneficial for preventing DVT but is not the immediate intervention for a suspected case. Monitoring oxygen saturation (choice D) is important for assessing respiratory function but is not the primary intervention for DVT treatment.