What is the most appropriate action for a client with a history of asthma who is experiencing wheezing?

Correct Answer: A

Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps open the airways, relieving wheezing in asthma patients. It is the first-line treatment for acute asthma exacerbations. Antihistamines (B) do not treat asthma symptoms. Monitoring for infection (C) is important but not the immediate action for wheezing. Epinephrine (D) is used for severe allergic reactions, not routine asthma management.

Correct Answer: A

Rationale: The correct answer is A: Increased respiratory rate and dyspnea. After a lung resection, complications like atelectasis or pneumonia can occur, leading to respiratory distress. Monitoring respiratory rate and dyspnea helps detect these issues early. Incorrect choices: B: Constipation and abdominal distension are not directly related to post-operative lung resection complications. C: Nausea and vomiting are more likely related to gastrointestinal issues rather than lung resection. D: Muscle weakness and fatigue are not specific signs of complications following a lung resection.

Correct Answer: A

Rationale: The correct answer is A: variable decelerations. Variable decelerations are abrupt decreases in fetal heart rate that vary in depth, duration, and timing, which can indicate cord compression. The variability in these decelerations suggests that the umbilical cord is being compressed intermittently. Early decelerations (B) are usually caused by head compression during contractions and mirror the contractions, not indicating cord compression. Bradycardia (C) is a slow heart rate, which can be caused by various factors but is not specific to cord compression. Tachycardia (D) is a fast heart rate, which can also be caused by various factors but is not typically associated with cord compression.

Correct Answer: A

Rationale: The correct answer is A: Assess vital signs. Vital signs provide crucial information on the client's overall condition and can help identify any life-threatening issues. Monitoring vital signs such as blood pressure, heart rate, respiratory rate, and temperature can guide immediate interventions and determine the urgency of further assessments or treatments. Administering oxygen (B) would be appropriate after assessing vital signs. Performing an ECG (C) may be indicated later but is not the priority in this acute situation. Monitoring serum glucose levels (D) is not typically the first assessment in a client with severe abdominal pain.

Correct Answer: D

Rationale: The correct answer is D because it indicates a potential concern about the girl's mental health. This behavior may suggest a difficulty in socializing with peers of her own age, which could be a sign of emotional distress or developmental issues. This is concerning in the context of her parents' bitter divorce. A: Clinging to her mother is a common behavior for a child going through a stressful situation, so it may not necessarily indicate a mental health issue. B: Appearing angry and avoiding eye contact could also be a normal reaction to stress or discomfort. C: Riding a tricycle is a typical activity for a 5-year-old and may not directly relate to mental health concerns.

Correct Answer: A

Rationale: The correct answer is A: Breathing, pain, sleep. Prioritizing breathing is crucial as it is a life-threatening issue. Pain should be addressed next to ensure the patient's comfort and well-being. Sleep can be addressed last as it is a lower priority compared to breathing and pain. Prioritizing in this order ensures the patient's immediate needs are met first. Choice B is incorrect because sleep should not take precedence over pain when the patient is in acute pain. Choice C is incorrect because addressing sleep before breathing and pain can be detrimental to the patient's health. Choice D is incorrect because breathing should be the top priority over both pain and sleep.

Correct Answer: A

Rationale: The correct answer is A: Administering bronchodilators as prescribed. Rationale: 1. Bronchodilators help dilate the airways, improving airflow in COPD patients. 2. Priority is to address the underlying respiratory issue. 3. Bronchodilators are a standard treatment for managing COPD symptoms. 4. Improving airway patency is crucial in COPD exacerbations. Summary: - B: Encouraging avoidance of physical activity is incorrect as it can lead to deconditioning. - C: Providing supplemental oxygen is important but not the priority in this case. - D: Monitoring for acute kidney injury is unrelated to COPD management.

Correct Answer: B

Rationale: The correct answer is B: Monitor for signs of infection. Within the first 48 hours post-op, fever is often indicative of an infection. Monitoring for signs such as increased pain, redness, swelling, warmth at the surgical site, elevated white blood cell count, and changes in vital signs helps in early detection and prompt treatment of infections. Administering antipyretics (choice A) may help reduce fever but does not address the underlying cause. Administering fluids (choice C) is important for hydration but does not directly address the fever's cause. Performing an abdominal assessment (choice D) is not specific to addressing fever in a post-op client.

Correct Answer: B

Rationale: The correct answer is B because increasing physical activity and reducing stress are important lifestyle changes for managing chronic hypertension. Exercise helps lower blood pressure and stress reduction techniques can help control hypertension. Option A is incorrect as reducing sodium intake, not increasing it, is recommended. Option C is incorrect as medications for hypertension should be taken as prescribed, not only when blood pressure increases. Option D is incorrect as monitoring blood pressure should be done regularly, but not necessarily every week.