Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. This is the first step in the care of a client with acute chest pain because nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can relieve chest pain associated with angina or heart attack. Administering aspirin (choice B) is important as well, but nitroglycerin is prioritized due to its immediate effect in reducing chest pain. Administering opioids (choice C) and morphine (choice D) are not recommended as first-line treatments for acute chest pain, as they can mask symptoms and delay the diagnosis of potentially life-threatening conditions.

Correct Answer: B

Rationale: The correct answer is B: Provide cooling measures. When caring for a client with hyperthermia, the nurse's priority is to lower the body temperature to prevent further complications. Providing cooling measures such as removing excess clothing, using fans, applying cool compresses, and encouraging hydration helps to reduce the body temperature effectively. Administering antipyretics (A and D) may be considered in some cases, but cooling measures are more immediate and effective. Administering corticosteroids (C) is not indicated in the treatment of hyperthermia. Cooling measures directly target the elevated body temperature, making it the top priority in managing hyperthermia.

Correct Answer: D

Rationale: The correct answer is D: Objective. During a physical assessment, the nurse gathers data through observation and measurement, such as vital signs and physical appearance, which are objective and measurable. This type of data is based on facts rather than opinions or interpretations, making it reliable for assessing the client's health status. Patient-centered data (A) refers to information focused on the client's perspective, subjective data (B) is based on the client's symptoms or feelings, and unconfirmed data (C) lacks validation or evidence, making them unreliable for making clinical decisions.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. In hypovolemic shock, there is a significant decrease in blood volume leading to inadequate perfusion of tissues. Administering IV fluids helps to restore circulating volume and improve tissue perfusion, which is crucial in managing hypovolemic shock. Elevating the client's legs (B) may be beneficial in other types of shock but not specifically in hypovolemic shock. Administering pain relief (C) and corticosteroids (D) are not the priority in hypovolemic shock as they do not address the underlying issue of decreased blood volume and tissue perfusion.

Correct Answer: A

Rationale: The correct answer is A: Vital signs. Assessing vital signs is crucial in a client presenting with symptoms of dehydration because it provides immediate information on the client's overall condition, including heart rate, blood pressure, respiratory rate, and temperature. Changes in vital signs can indicate the severity of dehydration and guide the nurse in determining the appropriate interventions. Summary: - B: Urine output is important in assessing dehydration but may not provide immediate information on the client's current condition compared to vital signs. - C: Skin turgor is a sign of dehydration but may not be the most accurate or immediate indicator compared to vital signs. - D: Skin color can also provide information on dehydration, but assessing vital signs gives a more comprehensive picture of the client's condition.