What is the most appropriate action for a nurse to take when a client develops a deep vein thrombosis (DVT)?

Correct Answer: D

Rationale: I must correct you on this question. The correct answer for the most appropriate action for a nurse to take when a client develops a deep vein thrombosis (DVT) is not D. The correct answer should be C: Provide anticoagulant therapy. Anticoagulant therapy is the standard treatment for DVT to prevent the blood clot from getting larger and to reduce the risk of it breaking loose and causing a pulmonary embolism. Elevating the leg and applying compression can help with symptoms but are not the primary treatment for DVT. Massage is contraindicated as it can dislodge the blood clot.

Correct Answer: D

Rationale: The correct answer is D: Assessment. Assessment is the first step in the nursing process where data is collected through health history, physical examination, and interview. This step helps in identifying the patient's needs and health problems. Planning (A) comes after assessment and involves setting goals and creating a care plan. Diagnosis (B) is the step where nursing diagnoses are formulated based on the assessment data. Evaluation (C) is the final step where the effectiveness of the care plan is assessed. In summary, Assessment is the initial step focused on data collection, making it the correct choice.

Correct Answer: B

Rationale: The correct answer is B: Encourage fluid intake. Adequate hydration helps in pain management by promoting circulation and reducing inflammation. Opioids (choice A) should only be used if non-pharmacological interventions fail. Administering oxygen (choice C) is not typically indicated for pain management. Monitoring electrolyte levels (choice D) is important but not the most immediate intervention for acute pain post-surgery.

Correct Answer: D

Rationale: The correct answer is D: Reactions to previous hospitalizations. Before any medical procedure, it is crucial to gather information about the child's previous reactions to hospitalizations to ensure the safety and well-being of the child during the tonsil removal. This information helps healthcare providers anticipate and prevent potential complications based on past experiences. A: The child's birth weight is irrelevant to the tonsil removal procedure and does not impact the current situation. B: The age at which he started to crawl is not relevant to the tonsil removal procedure and does not provide any useful information for the medical staff. C: Whether he has had the measles is not directly related to the tonsil removal procedure and does not influence the immediate care needed for the child.

Correct Answer: A

Rationale: The correct answer is A: Breath sounds and oxygen saturation. In COPD, monitoring respiratory status is crucial due to impaired gas exchange. Assessing breath sounds helps identify any adventitious sounds like wheezing or crackles, indicating respiratory distress. Oxygen saturation reflects oxygenation status, vital for patients with COPD prone to hypoxemia. Nutritional intake and weight (B), bowel sounds and abdominal girth (C), and urine output and skin integrity (D) are important but secondary assessments in this case. Nutritional status and weight are important for overall health, bowel sounds and abdominal girth are related to gastrointestinal function, and urine output and skin integrity are indicators of hydration and overall skin health, respectively. However, in a patient with COPD, the priority is ensuring adequate oxygenation and respiratory function.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. In severe allergic reactions, such as anaphylaxis, epinephrine is the first-line treatment as it rapidly reverses life-threatening symptoms like airway constriction and low blood pressure. Antihistamines (choice B) may help with mild symptoms but are not sufficient for severe reactions. Applying a cold compress (choice C) is not effective in treating anaphylaxis. Encouraging deep breathing (choice D) is not appropriate as the client may have difficulty breathing due to airway constriction. Administering epinephrine is crucial to quickly stabilize the client's condition in a severe allergic reaction.

Correct Answer: A

Rationale: The correct answer is A because as a nurse, it is essential to respect and accommodate the cultural beliefs and preferences of patients. By offering to assist in arranging for the presence of the medicine woman, the nurse shows empathy, cultural competence, and patient-centered care. This approach promotes trust, communication, and collaboration with the patient. Choice B is incorrect as it disregards the patient's request and shows a lack of respect for their beliefs. Choice C is incorrect as it dismisses the significance of the patient's request, which can impact the therapeutic relationship. Choice D is incorrect as it invalidates the patient's beliefs and cultural practices, which can lead to feelings of disrespect and lack of trust.

Correct Answer: A

Rationale: The correct answer is A - Administer IV fluids. This is the priority intervention for a client with suspected hypovolemia and hypotension as it helps to restore intravascular volume and improve blood pressure. IV fluids will address the underlying cause of hypotension by increasing circulating volume. Monitoring blood pressure (B) is important but administering IV fluids takes precedence. Administering corticosteroids (C) is not indicated for hypovolemia and hypotension. Administering oxygen (D) may be necessary if there is evidence of hypoxia, but addressing fluid volume status is the primary concern in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Apply a sterile dressing. This is the most important intervention to prevent infection and protect the wound. Applying a sterile dressing helps maintain a clean environment, reduces the risk of contamination, and promotes wound healing. Administering fluids (B) may be necessary but is not the top priority. Administering IV antibiotics (C) may be required but is secondary to wound care. Monitoring for bleeding (D) is important but addressing the wound with a sterile dressing takes precedence to prevent infection.