What is the most effective action when a client with a history of stroke develops difficulty speaking?

Correct Answer: B

Rationale: The correct answer is B: Administer thrombolytics. Thrombolytics help dissolve blood clots, which may be causing the stroke. Administering thrombolytics promptly can improve blood flow to the brain, potentially reducing the severity of the stroke and its effects, including difficulty speaking. Calling for help (A) is important, but administering thrombolytics should be a priority. Performing a CT scan (C) may help confirm the type of stroke but may delay immediate treatment. Administering bronchodilators (D) is not indicated for difficulty speaking related to stroke.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. The initial priority in managing sepsis is to restore perfusion and oxygenation by giving IV fluids to support blood pressure and organ perfusion. This helps to improve tissue oxygenation and prevents further organ damage. Administering insulin (choice B) is not the priority in the initial management of sepsis. Monitoring blood pressure (choice C) is important but not the first step in the management of sepsis. Administering insulin is also listed twice and is not relevant to the immediate management of sepsis.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. When a client presents with symptoms of hypoglycemia, the nurse should prioritize raising the blood sugar levels immediately to prevent further complications. Administering glucose helps to quickly address the low blood sugar levels and alleviate symptoms. Monitoring blood glucose (B) is important but not the first step in an acute situation. Administering insulin (C) would worsen hypoglycemia. Monitoring for arrhythmias (D) is not the primary concern when dealing with hypoglycemia.

Correct Answer: A

Rationale: Administering aspirin is the most appropriate intervention for a client experiencing a heart attack. Aspirin helps prevent blood clot formation, which is crucial in reducing further damage to the heart during a heart attack. It inhibits platelets from clumping together, improving blood flow to the heart muscle. Thrombolytics are used to dissolve existing blood clots, but aspirin is more preventive. Monitoring for arrhythmias is important but not the initial intervention. Administering morphine can be considered for pain relief but is not as crucial as administering aspirin to prevent further clot formation.

Correct Answer: A

Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps open airways, making it effective in treating respiratory distress. It works quickly to relieve symptoms such as shortness of breath and wheezing. Corticosteroids (B) may be used in conjunction with albuterol for severe cases, but albuterol is the immediate intervention. Providing pain relief (C) is not the primary intervention for respiratory distress. Nebulizers (D) are a delivery method for medications like albuterol, but the key intervention is administering the medication itself.