What are the first nursing actions of the nurse when a male client is admitted to the emergency department following an accident?

Correct Answer: A

Rationale: The correct answer is A because the first priority in emergency nursing is to assess the client's airway, breathing, circulation, and neurological response (ABCs). This approach ensures that life-threatening issues are addressed first. Checking respiration, circulation, and neurological response provides essential information on the client's immediate condition and guides further interventions. Choice B is incorrect because assessing the level of consciousness alone does not cover all critical aspects of the client's condition. Choice C is incorrect as checking pupils does not address the client's overall status comprehensively. Choice D is incorrect because stabilizing the spine should only be done after assessing the ABCs to ensure the client's immediate needs are met.

Correct Answer: B

Rationale: The correct answer is B because during an acute asthma attack, the airways become inflamed and swollen, making it difficult for air to pass through. This can result in a lack of audible breath sounds and the absence of wheezing. The swelling obstructs the flow of air, leading to decreased breath sounds. Choice A is incorrect as wheezing cessation does not necessarily indicate the end of an asthma attack. Choice C is incorrect because the swelling typically increases during an asthma attack. Choice D is incorrect as crackles are not associated with asthma attacks but may indicate other respiratory conditions like pneumonia.

Correct Answer: A

Rationale: The correct answer is A because in leukemia, increased white blood cell production crowds out red blood cells in the bone marrow, leading to anemia. The nurse should explain this to the client to address their confusion. Choice B is incorrect because white blood cells indeed contribute to anemia in leukemia. Choice C is unrelated and does not explain the anemia. Choice D is also incorrect as the issue lies in the overcrowding of red blood cells, not the lifespan of cells.

Correct Answer: C

Rationale: The correct answer is C, Clinical Nurse Specialist (CNS). A CNS has specialized training and credentialing, allowing them to provide expert clinical care, education, research, and leadership in a specific area of nursing practice. They have advanced knowledge and skills to improve patient outcomes and influence healthcare delivery. A: A Primary Care Nurse typically provides general healthcare services to a variety of patients. B: Private Duty Nurse provides one-on-one care to individual patients in their homes. D: A Visiting Nurse provides care to patients in their homes, but without the specialized training and credentialing of a CNS. In summary, the expanded role of a nurse with specialized training and credentialing is best represented by a Clinical Nurse Specialist due to their advanced clinical expertise and ability to impact healthcare on a broader scale.

Correct Answer: A

Rationale: The correct answer is A: Give laxative as ordered. In renal failure, constipation is common due to fluid and electrolyte imbalances. Laxatives can help soften stools and promote bowel movements without increasing fluid intake, which is restricted in renal failure. Increasing fluid intake (B) may worsen fluid overload. Raw fruits and vegetables (C) high in potassium and phosphorus can be harmful. Increasing activity (D) may not directly address the constipation issue.