What is the first step in the management of a client with acute renal failure?

Correct Answer: A

Rationale: The correct first step in managing a client with acute renal failure is to administer IV fluids (Choice A). This is crucial to ensure adequate hydration and maintain renal perfusion. By administering IV fluids, you can help improve kidney function and prevent further damage. Monitoring urine output (Choice B) is important but comes after addressing the fluid balance with IV fluids. Performing a CT scan (Choice C) is not typically the initial step in managing acute renal failure as it does not directly impact the patient's immediate condition. Administering diuretics (Choice D) can worsen the condition by further reducing kidney function, so it is not the recommended first step.

Correct Answer: A

Rationale: The correct answer is A: Fever. Fever is an early indicator of infection as it is the body's natural response to fighting off pathogens. When the body detects an infection, it raises its temperature to create an inhospitable environment for the pathogens. Pain at the surgical site (B) is common post-operatively but may not necessarily indicate infection. Redness at the incision site (C) can be a sign of inflammation but is not specific to infection. Increased heart rate (D) can occur due to various reasons post-operatively, not just infection. Fever is a systemic response and a more reliable early indicator of infection in this context.

Correct Answer: B

Rationale: The correct answer is B: Palpation. Palpation is the most effective technique for assessing the patient's abdominal organ size as it allows the healthcare provider to feel and evaluate the size, texture, and consistency of the abdominal organs through touch. This hands-on approach provides valuable information about any abnormalities or tenderness in the organs. Inspection (choice A) involves looking at the abdomen for any visible signs but does not provide information on organ size. Percussion (choice C) involves tapping on the abdomen to assess the density of underlying structures, not specifically organ size. Auscultation (choice D) involves listening to sounds within the abdomen and does not directly assess organ size. Palpation is the preferred method for accurately assessing abdominal organ size due to its tactile nature.

Correct Answer: C

Rationale: The correct answer is C: "I can stop taking my medication if I feel fine." This statement indicates a misunderstanding of the importance of medication adherence in managing heart failure. Here's the rationale: 1. Patients with heart failure often require lifelong medication to control symptoms and prevent complications. 2. Stopping medication abruptly can lead to worsening of heart failure symptoms and potential health risks. 3. Monitoring for symptoms is essential, but it does not replace the need for consistent medication use. Other choices are incorrect because: A is correct as daily medication adherence is crucial. B is correct as reducing sodium intake helps manage fluid retention in heart failure. D is correct as daily weight monitoring helps detect fluid retention early.

Correct Answer: A

Rationale: The correct answer is A: Administer warm IV fluids. This is because in severe hypothermia, the body's core temperature drops dangerously low, leading to decreased circulation and potential organ failure. Administering warm IV fluids helps to gradually raise the core temperature and prevent further complications. Choice B (Warming the client with a heating pad) can cause rewarming shock and skin burns. Choice C (Placing the client in a supine position) is not directly related to treating hypothermia. Choice D (Administering analgesics) is not the priority in treating severe hypothermia.

Correct Answer: A

Rationale: The correct answer is A: Patient's age and mobility. Age and mobility are key factors in pressure ulcer development as elderly and immobile patients are at higher risk due to decreased circulation and pressure on skin. Family medical history (B) is not directly linked to pressure ulcers. Frequency of hospital visits (C) is not a determining factor, and patient's education level (D) does not directly impact pressure ulcer risk. In summary, assessing age and mobility helps identify high-risk patients for developing pressure ulcers.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. When caring for a client with suspected hypoglycemia, the first priority is to raise their blood sugar levels quickly to prevent potential complications such as seizures or loss of consciousness. Administering glucose helps to rapidly increase blood sugar levels and alleviate symptoms. The other choices (B: Administer insulin, C: Place the client in a supine position, D: Administer IV fluids) are incorrect because administering insulin can further lower blood sugar levels, placing the client in a supine position may not address the immediate issue of low blood sugar, and administering IV fluids does not directly address the hypoglycemia.

Correct Answer: A

Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial for patients with diabetes and peripheral neuropathy to prevent complications like infections and ulcers. By inspecting their feet daily, the patient can identify any injuries or abnormalities early and seek prompt medical attention. This proactive approach can help prevent serious consequences such as amputations. Summary of incorrect choices: B: Taking medications only when experiencing symptoms - This is not recommended as medications for diabetes and neuropathy are often prescribed to prevent complications and manage the conditions on a daily basis. C: Exercising to increase foot circulation - While exercise is beneficial, patients with peripheral neuropathy may have decreased sensation in their feet, increasing the risk of injury during exercise. D: Wearing tight-fitting shoes to avoid blisters - Tight-fitting shoes can cause pressure points and increase the risk of foot injuries, especially in patients with neuropathy.

Correct Answer: A

Rationale: The correct first step is to immobilize the spine (A) in a suspected spinal cord injury to prevent further damage. This helps to stabilize the spine and prevent any potential movement that could worsen the injury. Providing pain relief (B) should come after immobilization. Assessing for signs of spinal shock (C) is important but comes after immobilization. Placing the client in a supine position (D) can be part of immobilization but is not the first step.