What is the most effective intervention for a client with shortness of breath and a history of heart failure?

Correct Answer: B

Rationale: The correct answer is B: Provide oxygen therapy. For a client with shortness of breath and a history of heart failure, oxygen therapy is the most effective intervention as it helps improve oxygenation and relieve respiratory distress. Administering diuretics may help manage fluid retention but does not directly address the breathing difficulty. Encouraging deep breathing may be beneficial for some respiratory conditions but may not be sufficient for a client with heart failure and shortness of breath. Applying oxygen therapy is similar to providing oxygen therapy and can help improve oxygen levels, but providing oxygen therapy is more specific and effective in this case.

Correct Answer: A

Rationale: The correct answer is A because capillary refill, warm toes, and no discomfort indicate good circulation and nerve function under the cast. This assessment helps detect any complications like impaired circulation or nerve damage. Posterior tibial pulses and moisture are not directly related to cast assessment. Pain threshold is subjective and does not provide objective information. Discomfort of the metacarpals is specific and not a comprehensive assessment.

Correct Answer: C

Rationale: The correct answer is C: Objective. Objective data in a physical assessment refers to measurable and observable information obtained through physical examination, laboratory tests, and diagnostic procedures. This type of data is crucial as it is based on facts and can be quantified. Subjective data (A) is based on the patient's feelings and experiences, while patient-centered (B) refers to care that is tailored to the individual's preferences. Diagnostic (D) data refers to information obtained through tests to determine a specific condition, which is different from the general data collected during a physical assessment.

Correct Answer: B

Rationale: The correct answer is B: Provide cooling measures. When caring for a client with hyperthermia, the nurse's priority is to lower the body temperature to prevent further complications. Providing cooling measures such as removing excess clothing, using fans, applying cool compresses, and encouraging hydration helps to reduce the body temperature effectively. Administering antipyretics (A and D) may be considered in some cases, but cooling measures are more immediate and effective. Administering corticosteroids (C) is not indicated in the treatment of hyperthermia. Cooling measures directly target the elevated body temperature, making it the top priority in managing hyperthermia.

Correct Answer: A

Rationale: The correct first step is to administer pain relief (Choice A) because addressing the client's pain is a top priority to ensure their comfort and well-being. Pain management is crucial post-surgery to prevent complications and aid in recovery. Monitoring vital signs (Choice B) is important but should follow pain relief to ensure the client's stability. Assessing the wound (Choice C) is necessary but not the immediate priority when the client is in acute pain. Applying a warm compress (Choice D) may provide temporary relief but does not address the underlying cause of the pain. Therefore, administering pain relief is the most appropriate initial action to alleviate the client's discomfort and start the healing process effectively.

Correct Answer: D

Rationale: The correct answer is D: Urologist consult. This is the appropriate intervention for a client with suspected genitourinary trauma and visible blood at the urethral meatus because a urologist is an expert in diagnosing and managing issues related to the genitourinary system. They can perform a thorough evaluation, order appropriate tests (such as imaging studies), and provide the necessary treatment for any potential trauma. Option A (Insert a Foley catheter) could worsen the trauma if there is an underlying injury. Option B (In and out catheter specimen) and Option C (Voided urine specimen) focus on specimen collection and do not address the potential trauma, making them inappropriate interventions in this situation. Consulting a urologist ensures proper assessment and management of the suspected genitourinary trauma.

Correct Answer: A

Rationale: Correct Answer: A - Administer antiemetics Rationale: The priority nursing action for a client vomiting post-surgery is to administer antiemetics to control nausea and vomiting, preventing complications like dehydration and electrolyte imbalance. Antiemetics help the client feel more comfortable and promote recovery. Administering fluids (choices B and C) is important, but addressing the vomiting itself takes precedence. Pain relief (choice D) is essential, but not the priority in this case.

Correct Answer: D

Rationale: The correct answer is D. When a client refuses medication, the nurse should document the refusal for legal and communication purposes. Informing the healthcare provider ensures ongoing assessment and potential alternatives. Choice A lacks communication with the healthcare team. Choice B may not address the underlying issue. Choice C assumes alternative treatment is necessary without further evaluation.

Correct Answer: D

Rationale: The correct answer is D - unexplained vaginal bleeding. This is a contraindication for hormone replacement therapy as it could indicate a serious underlying condition such as endometrial cancer. Hormone replacement therapy can increase the risk of endometrial cancer, so it should not be used in the presence of unexplained vaginal bleeding. A, B, and C are incorrect: A: Family history of stroke is not a direct contraindication for hormone replacement therapy. It may influence the decision-making process, but it is not a definitive contraindication. B: Ovaries removed before age 45 may actually be an indication for hormone replacement therapy to manage symptoms of menopause. C: Frequent hot flashes and/or night sweats are common symptoms of menopause and are not contraindications for hormone replacement therapy.