What is the highest priority for a nurse treating a client with a stab wound to the chest?

Correct Answer: A

Rationale: The correct answer is A: Secure the airway. This is the highest priority for a nurse treating a client with a stab wound to the chest because airway management is crucial for ensuring the client can breathe effectively. If the airway is compromised, the client may not be able to oxygenate properly, leading to serious complications or even death. Administering oxygen (choice B) can help with oxygenation but is not as critical as ensuring the airway is clear. Turning the client (choice C) or applying an abdominal binder (choice D) are not appropriate actions for a stab wound to the chest and would not address the immediate life-threatening issue of airway compromise.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis, a severe allergic reaction. It works by constricting blood vessels, increasing heart rate, and opening airways, which can reverse the life-threatening effects of an allergic reaction. Antihistamines (B) may help with mild symptoms but are not sufficient for severe reactions. Corticosteroids (C) are used to reduce inflammation but work too slowly for immediate relief. Beta-blockers (D) can worsen allergic reactions by blocking the effects of epinephrine.

Correct Answer: A

Rationale: The correct answer is A: Secure the airway. This is the highest priority for a nurse treating a client with a stab wound to the chest because airway management is crucial for ensuring the client can breathe effectively. If the airway is compromised, the client may not be able to oxygenate properly, leading to serious complications or even death. Administering oxygen (choice B) can help with oxygenation but is not as critical as ensuring the airway is clear. Turning the client (choice C) or applying an abdominal binder (choice D) are not appropriate actions for a stab wound to the chest and would not address the immediate life-threatening issue of airway compromise.

Correct Answer: A

Rationale: The correct answer is A: Assess the communication method preferred by the patient. This response is appropriate because it demonstrates person-centered care by respecting the patient's communication preferences. By assessing the patient's preferred communication method, the nurse can effectively communicate with the patient and provide the best care. Summary of other choices: B: Requesting a sign language interpreter may not be necessary if the patient does not use sign language. C: Using loud and exaggerated facial movements can be demeaning and ineffective in communication. D: Assuming all older adults have hearing deficits is a stereotype and may not be accurate for every individual.

Correct Answer: B

Rationale: The correct answer is B: "I can wear tight shoes to avoid blisters." Tight shoes can increase pressure on the feet, leading to blisters and worsening neuropathy symptoms. A: Inspecting feet daily is important to catch any issues early. C: Walking barefoot can increase the risk of injuries. D: Maintaining blood glucose levels within target range is crucial for managing diabetic neuropathy. In summary, the incorrect choices either provide important preventive measures or focus on key aspects of diabetes management, while the correct choice suggests a harmful behavior that can exacerbate neuropathy symptoms.

Correct Answer: B

Rationale: The correct answer is B: Sedation. Cancer patients taking opioids commonly experience sedation due to the central nervous system depressant effects of opioids. Opioids can cause drowsiness, fatigue, and decreased alertness. Tolerance (A) is a possible issue but is not the most common complication. Addiction (C) is less common in cancer patients due to the nature of their pain management. Constipation (D) is a common side effect of opioids but is not the most common complication in cancer patients. Sedation is the most prevalent issue affecting the quality of life and daily functioning of cancer patients on opioids.

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin is crucial for a client with acute MI as it helps prevent further blood clot formation by inhibiting platelet aggregation, reducing chances of additional cardiac events. Oxygen (B) is not routinely recommended unless hypoxemia is present. Morphine (C) can mask symptoms and delay treatment. Nitroglycerin (D) is used to relieve chest pain but may not be the most important intervention in acute MI. Administering aspirin promptly is vital to improve outcomes and reduce mortality in acute MI cases.

Correct Answer: A

Rationale: The correct answer is A: Liver. The liver is responsible for the extensive metabolism of acetaminophen through various pathways, including glucuronidation, sulfation, and oxidation. It converts acetaminophen into less toxic metabolites for elimination. The kidneys (B) primarily filter blood and regulate fluid balance; the lungs (C) are involved in gas exchange; and the pancreas (D) produces digestive enzymes and insulin, not involved in acetaminophen metabolism. Therefore, the liver is the correct choice for this question.

Correct Answer: B

Rationale: Step 1: Stroke patients are at increased risk for DVT due to immobility. Step 2: Monitoring for DVT signs is crucial for early detection and prevention. Step 3: Prompt intervention can prevent life-threatening complications. Step 4: Encouraging mobility (Choice A) is important but not the priority. Step 5: Administering antihypertensive meds (Choice C) may be necessary but not the priority. Step 6: Providing psychological support (Choice D) is important but not as critical as DVT monitoring.