What is the most effective action for a client with suspected sepsis?

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating sepsis as they help to fight the underlying infection causing the condition. Administering antibiotics promptly can prevent the infection from spreading and worsening. Fluids (choices B and C) are important for treating sepsis to maintain blood pressure and support organ function, but antibiotics are the primary intervention to target the infection. Administering oxygen (choice D) may be necessary to support respiratory function in septic patients, but it is not the most effective action to address the underlying infection.

Correct Answer: B

Rationale: Step 1: The nurse should prioritize collecting data based on the client's acuity to address immediate needs and ensure patient safety. Step 2: Acuity determines the urgency and intensity of care required, guiding the assessment focus. Step 3: Time available or client cooperation may influence the depth of assessment but do not dictate the data collected. Step 4: The onset of symptoms is important for history-taking but not the primary factor in determining assessment data.

Correct Answer: C

Rationale: Rationale for Correct Answer (C): Promoting activity is the most prioritized nursing intervention for a client with CHF. Activity helps improve cardiac function, decreases fluid accumulation, and enhances overall cardiovascular health. It also prevents complications like muscle weakness and deconditioning. It is crucial in managing CHF symptoms and improving the client's quality of life. Summary of Incorrect Choices: A: Administering diuretics helps in reducing fluid overload but does not address the underlying issue of improving cardiac function through physical activity. B: Limiting fluid intake is important, but promoting activity takes precedence as it directly impacts cardiac function and fluid accumulation. D: Maintaining fluid balance is necessary but is a broad concept that includes various interventions, with promoting activity being more focused and critical in CHF management.

Correct Answer: A

Rationale: The correct answer is A: Transfuse neutrophils. Neutrophil transfusion is not a standard treatment for neutropenia as neutrophils do not survive well outside the body. For the other choices: B: Excluding raw vegetables is correct to prevent infection. C: Avoiding rectal suppositories is correct to prevent mucosal injury. D: Prohibiting vases of fresh flowers is correct to prevent exposure to fungal spores. So, transfusing neutrophils is inappropriate as it is not a standard treatment for neutropenia.

Correct Answer: B

Rationale: The correct first intervention for a client suspected of having a stroke is to perform a CT scan (Choice B). This is because a CT scan can quickly identify the type of stroke (ischemic or hemorrhagic) and guide treatment decisions. Monitoring neurological status (Choice A) can be important but does not provide a definitive diagnosis. Administering fibrinolytics (Choice C) should only be done after confirming the type of stroke to avoid complications. Performing an MRI (Choice D) is more time-consuming and may not be feasible in the acute setting where quick intervention is crucial. Therefore, a CT scan is the most appropriate initial intervention for a suspected stroke.

Correct Answer: B

Rationale: The correct answer is B: Encouraging deep breathing and coughing exercises. This is prioritized in the immediate post-operative period to prevent respiratory complications like atelectasis and pneumonia. Deep breathing helps to expand the lungs and coughing helps clear secretions. Administering pain medication (A) is important but not the top priority. Monitoring for signs of infection (C) is crucial but usually done after ensuring respiratory stability. Providing solid food (D) is contraindicated initially to prevent post-operative complications like ileus.

Correct Answer: A

Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial in diabetic neuropathy to prevent complications such as infections and ulcers. By inspecting the feet daily, the patient can identify any injuries early and seek prompt treatment. Exercising (choice B) is important, but not the top priority. Taking pain medication (choice C) only addresses symptoms, not the root cause. Increasing protein intake (choice D) may be beneficial for healing, but foot inspection is more directly related to preventing complications in diabetic neuropathy.

Correct Answer: C

Rationale: The correct answer is C: Lower cholesterol. Foods that help lower cholesterol typically include sources of soluble fiber, plant sterols, and healthy fats like omega-3 fatty acids. These components can lower LDL (bad) cholesterol levels and reduce the risk of heart disease. Fiber-rich foods (choice A) are beneficial for lowering cholesterol due to their ability to bind to cholesterol and remove it from the body. Reduce diabetic ketoacidosis (choice B) is unrelated to lowering cholesterol and is a serious complication of diabetes. Reduce the need for folate (choice D) is not directly related to cholesterol levels. Thus, the correct choice is C as it directly addresses the question about lowering cholesterol.

Correct Answer: D

Rationale: The correct answer is D: Scurvy. Scurvy is caused by a deficiency in vitamin C, which is essential for collagen synthesis. Without enough vitamin C, collagen production is impaired, leading to symptoms like bleeding gums, fatigue, and joint pain. Incorrect Choices: A: Rickets is caused by a deficiency in vitamin D, not vitamin C. B: Marasmus is a severe form of malnutrition due to inadequate intake of calories and protein, not specifically vitamin C. C: Kwashiorkor is a form of severe acute malnutrition typically caused by inadequate protein intake, not vitamin C deficiency. In summary, the correct answer is D (Scurvy) because it directly relates to inadequate intake of vitamin C, while the other choices are associated with different nutrient deficiencies.