An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea. The nurse inserts a urinary catheter and observes dark amber urine output. Which intervention should the nurse implement first?

Correct Answer: C

Rationale: In this scenario, the nurse should implement the intervention C) Give a bolus of 0.9% sodium chloride 1000 mL over 30 minutes first. The dark amber urine output in an older client with a history of vomiting and diarrhea indicates severe dehydration and potential hypovolemic shock. Therefore, the priority is to restore intravascular volume quickly to improve perfusion and organ function. Option A) Beginning a dopamine infusion is not the priority as it focuses on increasing blood pressure but does not address the immediate need for volume replacement. Option B) Starting potassium chloride can be dangerous in a dehydrated patient as it can lead to hyperkalemia. Option D) Administering promethazine does not address the underlying issue of dehydration and could potentially worsen the patient's condition. Educationally, this question highlights the importance of prioritizing interventions based on the patient's condition and the urgency of the situation. Understanding the signs of dehydration and shock is crucial for nurses to provide timely and appropriate care, especially in critically ill patients. It also emphasizes the significance of fluid resuscitation in managing hypovolemia and improving patient outcomes.

Correct Answer: B

Rationale: In a client experiencing acute adrenal crisis, the nurse's first priority is to address the hemodynamic instability caused by the adrenal insufficiency. The correct answer, B) Administer an IV fluid bolus, is the most appropriate intervention as the client's vital signs indicate hypotension, which can be life-threatening. Administering IV fluids will help improve the client's blood pressure and perfusion to vital organs. Option A) Obtain an analgesic prescription is incorrect because pain management is not the priority in this situation. Option C) Administer PRN antipyretic is also incorrect as the client's symptoms are not suggestive of fever. Option D) Cover the client with a cooling blanket is not indicated as the client's vital signs indicate hypotension, which requires fluid resuscitation rather than cooling measures. Educationally, this question highlights the importance of prioritizing interventions based on the client's condition and vital signs in critical situations. It reinforces the concept of recognizing and managing acute adrenal crisis, a potentially life-threatening condition that requires prompt and appropriate interventions to stabilize the client's condition.

Correct Answer: D

Rationale: The correct answer is D) Measure the area of crackling and swelling. This action is essential because the cracking sensation could indicate subcutaneous emphysema, a potential complication of chest tube insertion. By measuring the area of crackling and swelling, the nurse can monitor for changes in size or severity, which can help in assessing the progression of the condition and guide further interventions. Option A) Apply a pressure dressing at the chest tube site is incorrect because applying pressure could exacerbate the subcutaneous emphysema by forcing air further into the tissues. Option B) Administer an oral antihistamine per PRN order is incorrect as antihistamines are not indicated for subcutaneous emphysema. Option C) Assess the client for allergies to topical cleaning agents is not relevant to the situation described and does not address the immediate concern of the cracking sensation during chest tube dressing change. In an educational context, understanding the importance of prompt assessment and action in response to unexpected findings during procedures is crucial for nurses caring for patients with chest tubes. Recognizing signs of complications like subcutaneous emphysema and knowing appropriate steps to take can prevent further harm and ensure optimal patient outcomes.

Correct Answer: A

Rationale: The correct answer is A) Use a glucometer to assess capillary glucose. This action is appropriate because the symptoms of increased hunger and thirst along with weight loss could indicate hyperglycemia, a common side effect of saquinavir and other antiretrovirals. By checking the client's capillary glucose levels, the nurse can assess for hyperglycemia and take appropriate action such as notifying the healthcare provider for medication adjustment or initiating interventions to manage high blood sugar levels. Option B) Explain to the client that an increased dose of medication is needed is incorrect because increasing the medication dose without assessing the client's glucose levels can exacerbate hyperglycemia and lead to further complications. Option C) Reassure the client that weight will improve as viral load decreases is incorrect as it does not address the immediate concern of potential hyperglycemia and weight loss. Option D) Teach the client how to measure his weight accurately is irrelevant to the client's current symptoms and does not address the potential underlying issue of hyperglycemia. In an educational context, this scenario highlights the importance of recognizing common side effects of antiretroviral medications, understanding the significance of symptoms such as increased hunger, thirst, and weight loss, and the need for timely assessment and intervention to ensure optimal client outcomes in HIV care. Regular monitoring and assessment of clients on antiretroviral therapy are essential to manage potential side effects effectively.

Correct Answer: A

Rationale: In this scenario, the most important action for the nurse to take is option A: Discuss alternative ways to support the client's birth plan. This option is the correct choice because it prioritizes client autonomy and respects the client's wishes while also ensuring their safety and well-being. By discussing alternative ways to support the client's birth plan, the nurse can explore options that align with the client's preferences while also addressing any potential concerns or risks associated with refusing induction at 42 weeks. This approach fosters a collaborative relationship between the nurse and the client, promoting trust and open communication. Option B, explaining the risks of induction after 42 weeks, while important, may come across as coercive and may not fully address the client's concerns or reasons for refusing induction. Option C shifts the responsibility to the healthcare provider without actively involving the client in the decision-making process. Option D focuses on the technical aspects of labor induction rather than the client's preferences and decision-making autonomy. Educationally, this scenario highlights the importance of client-centered care, shared decision-making, and effective communication in nursing practice. Nurses must respect and support clients' autonomous decision-making while also providing them with relevant information and guidance to make informed choices about their care.