What is the appropriate action for a healthcare provider to take when a patient has a high fever and is disoriented?

Correct Answer: C

Rationale: Administering fluids is the appropriate action for a healthcare provider to take when a patient has a high fever and is disoriented. Dehydration can worsen confusion and other symptoms in such a situation. Administering acetaminophen or cooling the patient with cold compresses may help reduce the fever but does not address the underlying issue. Administering antibiotics is not indicated for a high fever and disorientation without knowing the cause.

Correct Answer: B

Rationale: The correct answer is B: 'Heart rate of 88/min.' A heart rate of 88/min in a postoperative client can be an early sign of bleeding or other complications. It is essential to report this finding promptly to the healthcare provider for further evaluation and intervention. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate immediate concern. A blood pressure of 118/76 mm Hg is normal, urinary output of 30 mL/hr may be adequate depending on the client's fluid status, and a hematocrit of 42% is within the acceptable range for a postoperative client. Therefore, they do not require immediate reporting.

Correct Answer: A

Rationale: Encouraging compliance through education is crucial in helping patients understand the importance of consistent medication use. By providing education, the patient can make informed decisions about their health and better manage their condition. Contacting the healthcare provider (choice B) may be necessary in some cases, but the initial approach should focus on patient education. Documenting the refusal (choice C) is important for legal and medical records but does not address the root cause of non-compliance. Exploring alternative treatment options (choice D) should come after efforts to educate and encourage compliance with the current medication regimen.

Correct Answer: A

Rationale: The correct answer is to administer bronchodilators as the priority nursing action for a patient experiencing an acute asthma attack. Bronchodilators help open the airways and improve airflow, which is crucial in managing the acute respiratory distress in asthma. Corticosteroids may be used subsequently to reduce inflammation, but in the acute phase, bronchodilators take precedence. Providing supplemental oxygen is important but may not address the underlying bronchoconstriction characteristic of an asthma attack. Starting IV fluids is not a priority in managing an acute asthma attack unless indicated for specific reasons such as dehydration.

Correct Answer: A

Rationale: Clients should avoid consuming any food or drink for 8 hours before the glucose tolerance test to ensure accurate results. Choice A is the correct instruction for the client preparing for a glucose tolerance test. Drinking water, taking an antacid, or consuming milk before the test can interfere with the accuracy of the results. Water or any other substance might affect the concentration of glucose in the blood, leading to inaccurate test results. Antacids and milk can also interfere with the test outcome. Therefore, the client should follow the instruction to fast for 8 hours before the test.

Correct Answer: D

Rationale: A glomerular filtration rate of 14 mL/min indicates severe kidney impairment and the need for hemodialysis. The other choices, such as BUN 16 mg/dL, serum magnesium 1.8 mg/dL, and serum phosphorus 4.0 mg/dL, are within normal ranges and do not directly indicate the need for hemodialysis in chronic kidney disease.

Correct Answer: C

Rationale: Auscultating crackles in the lung bases indicates fluid in the lungs, which can be a sign of aspiration pneumonia or pulmonary edema and requires immediate intervention to prevent respiratory distress. Aspirating 100 mL of gastric residual is within the acceptable range and does not require immediate intervention. A gastric pH of 4 is normal for gastric contents. Checking residual every 6 hours is a routine nursing intervention and does not indicate an urgent issue like pulmonary complications.

Correct Answer: A

Rationale: The correct answer is to apply a hydrocolloid dressing. This type of dressing helps maintain a moist environment that is conducive to healing in stage 3 pressure ulcers. Providing wound debridement (choice B) is more suitable for higher stages of pressure ulcers where there is necrotic tissue. Changing the dressing daily (choice C) may be necessary but is not the primary action for a stage 3 pressure ulcer. Applying moist gauze (choice D) is not the recommended approach as it does not provide the same benefits as a hydrocolloid dressing.

Correct Answer: D

Rationale: The correct intervention for a client with a stage 3 pressure injury is to apply a moisture barrier ointment. This helps protect the skin, maintain moisture balance, and promote healing. Choice A is incorrect because povidone-iodine solution can be too harsh for wound care. Choice B is incorrect as hydrogen peroxide can be cytotoxic to healing tissue. Choice C is important for preventing pressure injuries but is not a direct intervention for a stage 3 wound.