A nurse is caring for a patient with diabetes who is receiving insulin. The nurse should be most concerned if the patient experiences:

Correct Answer: C

Rationale: The correct answer is C: Dizziness and shakiness. This indicates hypoglycemia, a potential side effect of insulin therapy. Dizziness and shakiness are classic signs of low blood sugar levels, which can be dangerous if left untreated. Headache and blurred vision (Option A) can occur with high blood sugar. Increased thirst and urination (Option B) are symptoms of hyperglycemia. Dry mouth and skin (Option D) are not immediate concerns related to insulin therapy.

Correct Answer: C

Rationale: The correct answer is C: Apply an airtight dressing. This is the first priority because it helps prevent air from entering the chest cavity, which can cause a tension pneumothorax. A tension pneumothorax can rapidly lead to respiratory distress and cardiac arrest. Applying an airtight dressing helps stabilize the condition until further medical intervention can be provided. Incorrect choices: A: Performing needle decompression is not the first priority as it is indicated for a tension pneumothorax once it has developed, not as a preventive measure. B: Applying a sterile dressing is important but not the first priority when dealing with a gunshot wound to the chest as sealing the wound to prevent air entry is more critical. D: Monitoring the client's ECG is not the first priority in this situation as addressing the potential tension pneumothorax takes precedence over monitoring the client's heart rhythm.

Correct Answer: A

Rationale: Step 1: Respect and compassion are essential in end-of-life care to support patients emotionally. Step 2: Nurses need to show empathy and understanding towards patients and their families. Step 3: Providing comfort and dignity in the final stages of life is crucial. Step 4: Assessing and intervening (Choice B) is important but not the primary competency in end-of-life care. Step 5: Setting goals and dynamic changes to care (Choice C) may be relevant but not as fundamental as respect and compassion. Step 6: Keeping sad news away (Choice D) goes against transparency and trust-building in end-of-life care.

Correct Answer: B

Rationale: The correct answer is B: Provide IV fluids. The first step in caring for a client with severe burn injuries is to ensure adequate hydration and prevent hypovolemic shock. IV fluids are crucial to replace lost fluids and maintain circulation. Cooling the burn site (choice A) may be important but not the first step. Providing pain relief (choice C) is important but not as critical initially. Initiating IV fluids (choice D) is similar to the correct answer, but providing IV fluids is more urgent than initiating them.

Correct Answer: B

Rationale: The correct answer is B because cleansing and dressing the wound is crucial in preventing further infection spread. First, cleansing the wound removes debris and pathogens, reducing the risk of infection. Second, dressing the wound protects it from external contaminants. This proactive approach promotes wound healing and prevents complications. A: Notifying the healthcare provider is important, but immediate wound care should be prioritized. C: Applying a dressing without cleansing the wound first may trap bacteria and worsen the infection. D: Pain medications are important for client comfort, but addressing the infection source is necessary for proper healing.

Correct Answer: A

Rationale: The correct answer is A. Assessing serum creatinine levels and GFR is crucial in monitoring kidney function in CKD patients. These tests provide information on the kidney's ability to filter waste products from the blood. Monitoring these levels helps in determining the stage of CKD and adjusting treatment plans accordingly. Blood glucose levels (B) are important in diabetes management but not the priority in CKD. Hemoglobin levels (C) are important for anemia assessment in CKD but not as critical as kidney function. Potassium levels (D) are important to monitor in CKD, but assessing kidney function takes precedence.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In respiratory distress, the priority is to ensure adequate oxygenation. Oxygen therapy helps improve oxygen levels in the blood and relieve respiratory distress. Administering diuretics (B) may not address the immediate need for oxygen. Increasing respiratory rate (C) may lead to worsening distress if the underlying cause is not addressed. Administering IV fluids (D) is not the priority unless specifically indicated for the client's condition. It is crucial to prioritize oxygen delivery to support vital functions and stabilize the client's condition.

Correct Answer: A

Rationale: The correct answer is A: Use a numeric pain scale. This method allows for quantitative assessment of pain intensity, aiding in accurate pain management. It is widely used in healthcare settings, providing a standardized way to communicate and monitor pain levels. Visual analog scale (B) is subjective and less precise than numeric scales. Facial expression scale (C) may be influenced by cultural factors and is subjective. Observing for signs of depression (D) is important but not specific to assessing pain intensity.

Correct Answer: B

Rationale: Step 1: Administering IV antibiotics is important for treating infections, but in this case, the focus is on addressing the pain associated with the deep wound infection. Step 2: Administering pain relief helps improve the client's comfort and quality of life while the infection is being treated. Step 3: Changing the dressing is essential for wound care but does not directly address the client's pain from the infection. Step 4: Performing a CT scan may be necessary to assess the extent of the infection, but it does not directly provide immediate relief for the client's pain. Summary: Administering pain relief is the most appropriate intervention as it directly addresses the client's symptoms and improves their comfort level during the treatment of the deep wound infection.