What is the best nursing action for a client with a wound infection?

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. This is the best nursing action for a client with a wound infection because antibiotics are necessary to treat the infection at its source, targeting the bacteria causing the infection. Antibiotics help prevent the infection from spreading and promote healing. Explanation of why other choices are incorrect: B: Applying a sterile dressing is important for wound care but does not address the underlying infection. C: Monitoring blood pressure is important for overall patient assessment but does not directly treat the wound infection. D: Placing the client in a sitting position is not relevant to treating a wound infection.

Correct Answer: A

Rationale: Step-by-step rationale for why choice A is correct: 1. Monitoring blood glucose levels regularly allows for timely adjustments in treatment. 2. It helps in preventing hypoglycemia or hyperglycemia complications. 3. Enables the patient to understand how their lifestyle choices impact their blood sugar levels. 4. Empowers the patient to make informed decisions regarding their diabetes management. Summary of why the other choices are incorrect: B: Limiting physical activity can lead to complications like obesity and decreased insulin sensitivity. C: Diet should focus on balanced nutrition, not just low-fat or high-protein, to manage diabetes effectively. D: Taking insulin regardless of blood sugar levels can result in hypoglycemia or poor blood sugar control.

Correct Answer: D

Rationale: The correct answer is D because completing the grieving process before birth is not appropriate when planning care for a client undergoing genetic counseling. This is because genetic counseling aims to provide information and support to help clients make informed decisions about their pregnancy or future child's health. Grieving before birth implies assuming a negative outcome before all information is gathered, which can be premature and may not align with the purpose of genetic counseling. Choices A, B, and C are allowed as they involve valid actions such as decision-making, preparation, and accessing support services, all of which are important aspects of genetic counseling.

Correct Answer: B

Rationale: The correct answer is B: Sedation. Cancer patients taking opioids commonly experience sedation due to the central nervous system depressant effects of opioids. Opioids can cause drowsiness, fatigue, and decreased alertness. Tolerance (A) is a possible issue but is not the most common complication. Addiction (C) is less common in cancer patients due to the nature of their pain management. Constipation (D) is a common side effect of opioids but is not the most common complication in cancer patients. Sedation is the most prevalent issue affecting the quality of life and daily functioning of cancer patients on opioids.

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. Peritonitis is an inflammation of the peritoneum typically caused by infection. Administering antibiotics is crucial to treat the underlying infection. IV fluids (B) may be necessary to maintain hydration, but antibiotics address the root cause. Placing the client in a supine position (C) is not a specific intervention for peritonitis. Administering epinephrine (D) is not indicated for peritonitis as it is not a treatment for infection.

Correct Answer: C

Rationale: The correct answer is C: 12. At 18 months, a child should have 12 teeth, which include 8 incisors and 4 molars. This is because children typically start teething around 6 months, with the lower central incisors coming first. By 18 months, they should have all 8 incisors and usually the first set of molars. Options A, B, and D are incorrect because they do not align with the typical dental development timeline for children. Having only 6, 8, or 16 teeth at 18 months would indicate a delay or abnormality in dental growth.

Correct Answer: B

Rationale: Step 1: Stroke patients are at increased risk for DVT due to immobility. Step 2: Monitoring for DVT signs is crucial for early detection and prevention. Step 3: Prompt intervention can prevent life-threatening complications. Step 4: Encouraging mobility (Choice A) is important but not the priority. Step 5: Administering antihypertensive meds (Choice C) may be necessary but not the priority. Step 6: Providing psychological support (Choice D) is important but not as critical as DVT monitoring.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In acute shortness of breath with COPD, oxygen therapy is crucial to improve oxygenation levels and alleviate respiratory distress. Oxygen can help reduce the workload on the lungs and heart. Antibiotics (B) are not indicated unless there is a suspected bacterial infection. Monitoring blood glucose (C) is important in diabetes management but not the priority in acute respiratory distress. Administering pain relief (D) may not address the underlying cause of the shortness of breath. Oxygen therapy directly targets the respiratory issue in COPD exacerbation, making it the most effective initial intervention.

Correct Answer: A

Rationale: The correct answer is A: Administer antiepileptics. This is the most appropriate intervention for a client with a history of seizures as antiepileptic medications help prevent or reduce the frequency of seizures. Monitoring vital signs (B) is important but does not directly address the underlying issue of seizures. Oxygen therapy (C) may be needed during a seizure but does not prevent future episodes. Monitoring ECG (D) may provide information on cardiac function but is not the primary intervention for seizures. Administering antiepileptics is essential for seizure management.