What is the most appropriate intervention for a client with a severe burn?

Correct Answer: D

Rationale: The correct answer is D: Cover the burn site with a clean, dry dressing. This intervention helps protect the burn from infection, promotes healing, and reduces pain. Ice can further damage the skin. Pain medication may be needed but does not address wound care. Maintaining a sterile dressing is crucial, but covering with a clean, dry dressing is more practical and achievable in most settings.

Correct Answer: B

Rationale: The primary goal for a client with newly diagnosed diabetes is to monitor their blood glucose levels (Answer B). This is essential to understand how their body responds to different foods, activities, and medications. Monitoring blood glucose levels helps in determining the effectiveness of the treatment plan and making necessary adjustments. Teaching the client how to manage their blood glucose levels (Answer A) is important, but monitoring comes first. Monitoring urine output (Answer C) is not as relevant for diabetes management. Administering insulin (Answer D) may be necessary in some cases, but it is not the primary goal initially.

Correct Answer: C

Rationale: The correct answer is C: Check for dehydration. When a client has a high fever, assessing for dehydration is crucial because fever can lead to increased fluid loss through sweating and increased respiratory rate. Dehydration can exacerbate the client's condition and needs to be addressed promptly. Monitoring respiratory rate (choice A) and pulse (choice D) are important assessments but do not address the immediate need to identify dehydration. Obtaining a blood sample (choice B) may be necessary at some point but is not the initial priority in a client with a high fever. Thus, checking for dehydration should be assessed first to ensure proper management of the client's condition.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. The priority in a severe allergic reaction is to quickly address the life-threatening symptoms like anaphylaxis. Epinephrine is the first-line treatment as it helps reverse the effects of the allergic reaction by opening airways and increasing blood pressure. Administering antihistamines (choices B and D) can help relieve itching and hives but are not as effective in treating severe symptoms. Monitoring respiratory status (choice C) is important but administering epinephrine takes precedence to stabilize the client's condition.

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.