What is the first priority when caring for a client with a gunshot wound to the chest?

Correct Answer: C

Rationale: The correct answer is C: Apply an airtight dressing. This is the first priority because it helps prevent air from entering the chest cavity, which can cause a tension pneumothorax. A tension pneumothorax can rapidly lead to respiratory distress and cardiac arrest. Applying an airtight dressing helps stabilize the condition until further medical intervention can be provided. Incorrect choices: A: Performing needle decompression is not the first priority as it is indicated for a tension pneumothorax once it has developed, not as a preventive measure. B: Applying a sterile dressing is important but not the first priority when dealing with a gunshot wound to the chest as sealing the wound to prevent air entry is more critical. D: Monitoring the client's ECG is not the first priority in this situation as addressing the potential tension pneumothorax takes precedence over monitoring the client's heart rhythm.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis as it quickly reverses severe allergic reactions. It works by constricting blood vessels, relaxing airway muscles, and increasing heart rate. These actions help to counteract the potentially life-threatening symptoms of anaphylaxis, such as difficulty breathing and a drop in blood pressure. Applying antihistamines (B) may help with mild allergic reactions but are not sufficient for anaphylaxis. Administering morphine (C) or pain relief (D) is not appropriate initially as they do not address the immediate life-threatening nature of anaphylaxis.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help dilate the airways, relieving bronchospasm and improving airflow in clients experiencing shortness of breath and wheezing. This intervention directly addresses the underlying cause of the symptoms. Administering corticosteroids (B) may be considered in severe cases to reduce inflammation but is not the priority initial intervention. Administering pain relief (C) is not indicated unless pain is identified as a contributing factor. Placing the client in a sitting position (D) can help improve breathing but does not directly address the bronchoconstriction causing the wheezing.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. The first priority in caring for a client experiencing a stroke is to ensure adequate oxygen supply to the brain, as lack of oxygen can lead to further brain damage. Administering oxygen helps improve oxygenation and can prevent complications. Administering morphine (B) is not recommended as it can mask symptoms and delay diagnosis. Administering IV fluids (C) may be necessary but is not the first priority. Administering fibrinolytics (D) is a time-sensitive intervention for ischemic stroke but should be done after proper evaluation and confirmation of the type of stroke.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants are the primary treatment for DVT as they prevent blood clots from getting bigger and reduce the risk of new clots forming. This helps prevent complications like pulmonary embolism. Elevating the leg and applying compression (option B) can help with symptoms but do not address the underlying cause. Providing anticoagulant therapy (option C) is similar to the correct answer but lacks specificity. Applying compression stockings (option D) can help prevent complications but do not treat the existing clot.

Correct Answer: B

Rationale: The correct answer is B: Increase potassium intake. Potassium helps to lower blood pressure by counteracting the effects of sodium. This dietary change is crucial for managing hypertension. Increasing sodium intake (choice A) is incorrect as it can lead to increased blood pressure. Increasing fiber intake (choice C) is beneficial for overall health but not specifically for hypertension. Increasing alcohol intake (choice D) is harmful and can worsen hypertension. Prioritizing increasing potassium intake is essential for effectively managing hypertension.

Correct Answer: C

Rationale: The correct intervention for hyperkalemia is to administer insulin (Choice C). Insulin drives potassium into cells, lowering serum potassium levels. This is effective in acutely reducing high potassium levels. Administering calcium gluconate (Choice A) is used for stabilizing cardiac membranes in hyperkalemia but does not lower potassium levels. Sodium bicarbonate (Choice B) is used for metabolic acidosis, not hyperkalemia. Furosemide (Choice D) is a loop diuretic that can lead to potassium loss but is not the primary intervention for hyperkalemia.

Correct Answer: A

Rationale: Step 1: Respect and compassion are essential in end-of-life care to support patients emotionally. Step 2: Nurses need to show empathy and understanding towards patients and their families. Step 3: Providing comfort and dignity in the final stages of life is crucial. Step 4: Assessing and intervening (Choice B) is important but not the primary competency in end-of-life care. Step 5: Setting goals and dynamic changes to care (Choice C) may be relevant but not as fundamental as respect and compassion. Step 6: Keeping sad news away (Choice D) goes against transparency and trust-building in end-of-life care.

Correct Answer: D

Rationale: A score of 6 on the MoCA tool indicates severe cognitive impairment because the MoCA is scored out of 30, with a lower score indicating more severe impairment. A score of 6 is significantly below the normal range, indicating severe cognitive deficits affecting various cognitive domains. This score would suggest significant impairment in memory, attention, language, visuospatial abilities, and executive functions. Therefore, Option D is correct. Options A, B, and C are incorrect as they suggest no, mild, or moderate impairment, which would not align with a score as low as 6 on the MoCA tool.