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: 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: B

Rationale: The correct answer is B: Monitoring serum albumin levels. This is because serum albumin is a protein synthesized by the liver that reflects long-term protein intake and overall nutritional status. Low levels indicate malnutrition or inflammation. Obtaining a dietary history (choice A) is important but may not always reflect the actual nutritional status. Monitoring weight (choice C) is helpful but may not provide a comprehensive view of the client's nutritional status. Providing a meal plan (choice D) is a proactive approach but does not directly assess the client's current nutritional status.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. Nitroglycerin is the recommended initial medication for chest pain in a client with a history of myocardial infarction. It helps dilate blood vessels, improving blood flow to the heart, and reducing chest pain. Aspirin (choice B) is also usually given to reduce blood clot formation, but nitroglycerin is the priority for immediate relief. Morphine (choice C) may be used if nitroglycerin is ineffective, and beta blockers (choice D) are typically used for long-term management of heart conditions, not for immediate relief of chest pain.

Correct Answer: A

Rationale: The correct first action is A: Apply pressure and elevate the limb. This is because applying pressure helps control bleeding and elevating the limb reduces blood flow to the area, minimizing further blood loss. This immediate intervention is crucial in managing the traumatic amputation and preventing complications. Summary of why other choices are incorrect: B: Stopping bleeding and controlling shock can be important but not the first action. C: Placing the client in a Trendelenburg position (feet elevated higher than the head) is contraindicated in cases of traumatic amputation as it can increase bleeding. D: Placing the client in a sitting position is not appropriate as it can worsen bleeding and lead to further complications.

Correct Answer: B

Rationale: The correct answer is B because asking someone who knows the patient well can provide valuable insight into the meaning behind the verbal and nonverbal communication discrepancy. This helps in understanding the context and potential reasons for the inconsistency. Option A is incorrect as ignoring nonverbal behaviors can lead to missing important cues. Option C of interpreting messages as an 'average' may oversimplify the complexity of communication. Option D is incorrect as while nonverbal behaviors can provide valuable information, solely focusing on them may not give a complete understanding of the situation.

Correct Answer: B

Rationale: The correct answer is B because conveying respect for differences helps build trust and encourages patients to share their perspectives openly. This fosters a positive patient-provider relationship and enhances communication. Choice A is incorrect as patients have unique behaviors. Choice C is incorrect as cultural expectations do not fully explain individual differences. Choice D is incorrect as expressing one's culture is not solely dependent on exposure to Canadian values.

Correct Answer: B

Rationale: The correct answer is B: Do not use underarm deodorant. This is important because deodorant can interfere with the mammogram results, leading to false readings. It is crucial to have a clean and uncontaminated image for an accurate diagnosis. Choice A is incorrect as it can affect the quality of the mammogram. Choices C and D are irrelevant to the mammography procedure and not necessary instructions for the client.

Correct Answer: A

Rationale: The correct answer is A: Perform a CT scan. This is the priority action because it helps determine if the stroke is ischemic or hemorrhagic, guiding treatment decisions. Monitoring blood pressure (B) is important but not the priority. Administering aspirin (C) can be considered after confirming the type of stroke. Administering thrombolytics (D) is indicated for ischemic stroke but should only be done after ruling out hemorrhagic stroke with a CT scan.