What is the first action the nurse should take when a client develops a deep vein thrombosis (DVT)?

Correct Answer: A

Rationale: The correct answer is A: Elevate the affected leg. This is the first action because elevating the leg helps reduce swelling and improve blood flow, reducing the risk of complications from the DVT. It also helps alleviate pain. Choice B: Applying compression stockings can be helpful in preventing DVT, but it is not the first action to take once it has developed. Choice C: Providing leg elevation is similar to choice A, but it lacks the specificity of elevating the affected leg to address the DVT directly. Choice D: Administering compression therapy may be necessary, but it is not the initial action to take when a client develops a DVT.

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: B

Rationale: The correct answer is B: Monitor for arrhythmias. This is because in a client showing signs of shock after surgery, the priority is to assess for any cardiac complications such as arrhythmias, which can be life-threatening. Monitoring for arrhythmias allows prompt identification and intervention. Administering a blood transfusion (A) may be necessary in some cases of shock but is not the first intervention. Administering oxygen (C) may also be necessary, but addressing cardiac complications takes precedence. Encouraging deep breathing (D) is not a priority in managing shock-related complications.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help to relax and open up the airways, which can alleviate shortness of breath and chest tightness in conditions like asthma or COPD. Administering oxygen (choice B) can help if the client is hypoxic, but it does not directly address the underlying airway constriction. Applying a cold compress (choice C) may provide some comfort but will not address the respiratory distress. Administering IV antibiotics (choice D) is not indicated for shortness of breath and chest tightness unless there is an underlying bacterial infection.

Correct Answer: A

Rationale: The correct answer is A: Immobilize the spine. This is the first priority because it helps prevent further injury to the spinal cord. By immobilizing the spine, the nurse ensures that any movement doesn't worsen the existing injury. Placing the client in a supine position (B) can be done after immobilization. Administering analgesics (C) should not be done before assessing the extent of the injury. Assessing the airway (D) is important but should come after immobilizing the spine to prevent any unnecessary movement.