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: D

Rationale: A focused assessment is more in-depth on specific issues, providing detailed information on a particular problem or concern. This allows for targeted interventions and treatment strategies. In contrast, a comprehensive assessment covers the body head to toe and involves all body systems, which may not be necessary when focusing on a specific issue. Occurring only in the clinic is a limitation to choice B, as assessments can be conducted in various settings. Involving all body systems, as stated in choice C, is not the primary focus of a focused assessment.

Correct Answer: D

Rationale: The correct answer is D: Administer diuretics. The priority for a nurse caring for a client with pneumonia is to maintain adequate oxygenation and prevent respiratory failure. Diuretics help reduce fluid overload in the lungs, improving gas exchange and oxygenation. Administering antibiotics (choice A) is important to treat the infection but not the top priority. Administering oxygen (choice B) is crucial for oxygenation, but diuretics take precedence to improve lung function. Administering corticosteroids (choice C) may be considered in certain cases to reduce inflammation, but it is not the primary priority.

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: A

Rationale: The correct answer is A: Assess airway. In caring for a client with a traumatic head injury, the first priority is to ensure there is a clear airway to maintain oxygenation and ventilation, which is crucial for brain function. If the airway is compromised, it can lead to hypoxia and further brain damage. Providing pain relief (B) is important but not the immediate priority. Monitoring intracranial pressure (C) is essential but comes after ensuring a patent airway. Maintaining a quiet environment (D) can help reduce stimulation, but it is not as critical as assessing the airway for immediate intervention.