What is the first intervention for a client who is at risk for dehydration?

Correct Answer: C

Rationale: Rationale: Choice C, apply ice, is the correct answer as the first intervention for a client at risk for dehydration. Applying ice helps to lower the body temperature, which can reduce sweating and fluid loss. This intervention is crucial in preventing further dehydration. Administering IV fluids (Choice A) may be necessary in severe dehydration cases, but it is not the first intervention. Administering oxygen (Choice B) is not directly related to dehydration. Elevating the leg (Choice D) is not effective in addressing dehydration. In summary, applying ice is the most appropriate initial intervention to prevent dehydration by reducing body temperature and fluid loss.

Correct Answer: A

Rationale: The correct answer is A: Monitor urine output. This is the most important action because it helps assess the client's fluid status and kidney function. Monitoring urine output can indicate if the client's body is effectively eliminating excess fluid. Elevating the head of the bed (B) helps with respiratory function but is not the priority in fluid overload. Administering diuretics (C) may be necessary but should be based on urine output monitoring. Encouraging deep breathing (D) is important for respiratory function but not directly related to managing fluid overload.

Correct Answer: B

Rationale: Mammography is used to detect tumors in the breast tissue. It is a screening tool for breast cancer. Tumors can be either benign or malignant. Mammograms help in early detection of abnormalities in breast tissue. Pain, edema, and epilepsy are unrelated to the purpose of mammography. Pain is a symptom, edema is swelling, and epilepsy is a neurological disorder. Therefore, the correct answer is B because mammography is specifically designed to detect tumors in the breast.

Correct Answer: A

Rationale: The correct answer is A: Administer pain relief. This is the priority action because managing pain is crucial in providing comfort and reducing distress for the client with a severe burn. Pain relief helps in improving the client's overall well-being and promotes better recovery. Administering corticosteroids (Choice B) is not the priority as pain relief takes precedence. Monitoring for infection (Choice C) is important but not the immediate priority. Applying dressings (Choice D) is also important but should come after administering pain relief.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. When a client with asthma develops wheezing, the primary action is to administer bronchodilators to help dilate the airways and improve breathing. This helps relieve the symptoms of wheezing and prevent further complications. Providing pain relief (Choice B) is not the primary action for wheezing in asthma. Encouraging deep breathing (Choice C) may worsen the wheezing in an asthma attack. Performing chest physiotherapy (Choice D) is not the first-line treatment for wheezing in asthma.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. The nurse's first action in treating hypoglycemia is to increase the client's blood glucose levels to prevent further complications. Administering glucose helps quickly raise blood sugar levels, addressing the immediate issue. Options B, C, and D are incorrect as administering insulin would further decrease blood sugar levels, administering oxygen is not the primary intervention for hypoglycemia, and administering antipyretics is used for reducing fever, not treating hypoglycemia.

Correct Answer: D

Rationale: In emergency situations, time is crucial. Emergency assessment is the most appropriate as it focuses on quickly identifying and addressing life-threatening issues. It involves a rapid but systematic evaluation of the patient's airway, breathing, circulation, and disability. Head-to-toe assessment (A) and comprehensive assessment (C) are too time-consuming in emergencies, whereas focused assessment (B) may not cover all critical aspects.

Correct Answer: D

Rationale: The correct answer is D: Administer morphine. Administering morphine is the first intervention for a client experiencing a myocardial infarction (MI) to help relieve pain and reduce anxiety. Oxygen may not be necessary if the client is not hypoxic. Administering aspirin is important but usually follows morphine. Monitoring ECG is crucial, but not the first intervention to address the immediate symptoms of MI.

Correct Answer: A

Rationale: The correct answer is A: Open the airway. This is the first intervention because ensuring a clear airway is crucial for adequate oxygenation. If the airway is obstructed, oxygen administered or suctioning performed may not be effective. Checking for breathing should follow airway opening. Administering oxygen can be done once the airway is established. Suctioning is not the priority unless there is evidence of airway obstruction.