A patient is assessing a client who has just been admitted to the emergency department. The client is having difficulty breathing and is using accessory muscles. What action by the nurse is best?

Correct Answer: D

Rationale: The correct answer is D: Place the client in a high Fowler's position. Placing the client in a high Fowler's position helps improve lung expansion and oxygenation by maximizing chest expansion. This position facilitates better breathing mechanics and can alleviate respiratory distress. Choice A is incorrect because administering oxygen via nasal cannula should be done after positioning the client properly. Choice B is important but assessing vital signs alone may not provide immediate relief to the client's breathing difficulty. Choice C, notifying the Rapid Response Team, is not the best immediate action as positioning the client correctly should be the priority before seeking additional help.

Correct Answer: B

Rationale: The correct answer is B: Short-acting beta agonist. During an acute asthma attack, the priority is to quickly relieve bronchoconstriction and improve airflow. Short-acting beta agonists like albuterol are the first-line medications for acute asthma exacerbations as they act rapidly to relax smooth muscles in the airways, providing immediate relief of symptoms. Oral corticosteroids (A) are important for long-term management but do not provide immediate relief. Leukotriene receptor antagonists (C) and long-acting beta agonists (D) are not appropriate for acute asthma attacks as they have slower onset of action and are used for maintenance therapy.

Correct Answer: C

Rationale: The correct answer is C because excessive alcohol consumption can raise blood pressure. Step 1: Alcohol can lead to hypertension. Step 2: Limiting alcohol intake is crucial in managing hypertension. Step 3: Choices A, B, and D promote healthy behaviors that help control blood pressure. Summary: Choice C is incorrect as it goes against hypertension management, while choices A, B, and D align with lifestyle modifications for hypertension.

Correct Answer: D

Rationale: The correct answer is D: Assess the client for any allergies, especially to iodine or shellfish. This is crucial because contrast dye containing iodine is commonly used during cardiac catheterization, and a client with allergies to iodine or shellfish can have a severe allergic reaction. It is essential to identify allergies beforehand to prevent any potential adverse reactions during the procedure. A: Ensuring NPO status is important for some procedures, but assessing for allergies is more critical to prevent life-threatening reactions. B: Administering pre-procedure medications is important, but assessing for allergies takes precedence to avoid allergic reactions. C: While obtaining informed consent is necessary, assessing for allergies is a crucial safety measure to prevent allergic reactions during the procedure.

Correct Answer: C

Rationale: The correct answer is C: Assessing for chest pain. The priority assessment for a client post-MI is to monitor for any signs of recurrent chest pain or angina, as it could indicate ongoing cardiac ischemia or a new infarction. Prompt intervention is crucial in these situations to prevent further damage to the heart muscle. Monitoring urine output (A) and electrolyte levels (D) are important assessments but do not take precedence over assessing for chest pain. Checking blood glucose levels (B) is relevant for diabetic clients but is not the priority in this case.