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: A

Rationale: The correct answer is A: Administer nitroglycerin. This is the nurse's first action for a client with a suspected MI because nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can help reduce chest pain and prevent further damage to the heart muscle. Administering nitroglycerin promptly is crucial in managing an MI. Monitoring cardiac rhythm (B) and assessing the ECG (C) are important steps, but administering nitroglycerin takes precedence in addressing the client's immediate symptoms. Assisting with positioning (D) is not as urgent or directly related to managing an MI compared to administering nitroglycerin.

Correct Answer: A

Rationale: Correct Answer: A Rationale: Using the inhaler when feeling an asthma attack coming on allows for prompt relief by opening airways. Waiting for symptoms to worsen (B) can lead to a severe attack. Using the inhaler only when short of breath (C) may delay treatment. Skipping the inhaler when feeling fine (D) can be dangerous if an attack occurs suddenly. Answer A ensures timely intervention for effective asthma management.

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: C

Rationale: The correct answer is C. Stopping insulin once blood glucose is normal is incorrect as insulin is crucial for managing diabetes even when blood glucose levels are within the target range. Insulin helps regulate blood sugar levels consistently, and stopping it abruptly can lead to hyperglycemia. Choices A, B, and D are correct statements indicating good diabetes management practices. Monitoring blood glucose levels, exercising regularly, and following a balanced diet are essential for controlling blood sugar levels and overall health.

Correct Answer: C

Rationale: The correct answer is C because the clothing of a trauma client could potentially be considered evidence with legal implications. Preserving the bloodstains or tears on the clothing maintains the integrity of the evidence for forensic investigation or legal proceedings. Disrupting the bloodstains or tears could compromise the evidence and hinder any potential investigation or legal case. Choices A, B, and D are incorrect because the primary concern in this scenario is the legal implications and preservation of evidence, not ownership, repair, salvage, or minimizing trauma to family members.

Correct Answer: C

Rationale: The correct answer is C because the statement made by the nurse implies a power dynamic that can create dependency and inferiority in the patient, which is not conducive to a patient-centered approach. In a healthcare setting, it is important to empower patients to be active participants in their care decisions rather than being passive recipients. Encouraging patients to blindly follow orders without understanding or questioning can lead to poor outcomes and lack of patient engagement. Therefore, it is best to avoid making statements that reinforce hierarchical relationships and instead foster open communication and shared decision-making. The other choices are incorrect because: A: This choice focuses on bias, which is not the main issue at hand in this scenario. B: While healthcare team members are experts in their respective fields, the emphasis should be on collaborative decision-making rather than blind obedience. D: Using authority statements may be necessary in certain situations, but it does not address the potential harm of creating dependency and inferiority in the patient.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. Oxygenation is the priority in stroke management to ensure adequate oxygen supply to the brain. Oxygen therapy can help reduce hypoxia, which is crucial in the acute phase of a stroke. Administering aspirin (B) is important but comes after ensuring oxygenation. Administering thrombolytics (C) requires proper assessment and diagnostic confirmation, not an immediate priority. Placing the client in a supine position (D) may worsen stroke symptoms if there is compromised blood flow, so it is not recommended as the initial action.

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.