What is the most appropriate action when a client presents with acute abdominal pain?

Correct Answer: C

Rationale: The correct answer is C: Monitor blood pressure. When a client presents with acute abdominal pain, monitoring blood pressure is crucial as it can help assess for potential complications like hypovolemic shock or internal bleeding. Changes in blood pressure may indicate worsening condition and prompt the need for immediate intervention. Monitoring vital signs (A) is important but blood pressure takes precedence in this scenario. Assessing abdominal tenderness (B) is valuable but does not directly address potential life-threatening issues. Monitoring for dehydration (D) is also important but not the most immediate concern in the case of acute abdominal pain.

Correct Answer: A

Rationale: The correct answer is A: Administer pain relief. The nurse's first priority is to address pain and ensure the client's comfort and well-being. Pain relief helps reduce distress, improve communication, and prevent complications. Monitoring blood pressure (B) and providing hydration (C) are important but not the immediate priority in severe trauma. Administering a blood transfusion (D) may be necessary but is not the first priority compared to addressing pain and stabilizing the client.

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: Apply a sterile dressing. Firstly, cover the wound with a sterile occlusive dressing to prevent air from entering the pleural space, reducing the risk of tension pneumothorax. This also helps to prevent infection and further complications. Administering morphine (B) or nitroglycerin (D) is not the priority in this situation as managing the chest wound is crucial. Applying an airtight dressing (C) may lead to tension pneumothorax if not done properly. Therefore, the immediate action should be to apply a sterile dressing to stabilize the wound and prevent further complications.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. The priority nursing action for a client experiencing severe chest pain is to administer nitroglycerin to help dilate the blood vessels and improve blood flow to the heart, reducing chest pain. This action helps to address the immediate issue of chest pain and potential heart damage. Administering morphine (B) may be considered if chest pain persists despite nitroglycerin. Administering oxygen (C) can also be helpful but is not the initial priority. Monitoring blood pressure (D) is important but not the most urgent action in this scenario.