What is the most effective intervention for a client with hypoglycemia?

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. Hypoglycemia is low blood sugar, and administering glucose rapidly raises blood sugar levels to restore normal function. Glucagon (choice B) is used for severe hypoglycemia when the individual cannot consume oral glucose. Insulin (choice C) lowers blood sugar levels and is contraindicated in hypoglycemia. Corticosteroids (choice D) can worsen hypoglycemia by affecting glucose metabolism. Administering glucose is the most direct and effective intervention for hypoglycemia.

Correct Answer: D

Rationale: The correct answer is D: Objective. During a physical assessment, the nurse gathers data through observation and measurement, such as vital signs and physical appearance, which are objective and measurable. This type of data is based on facts rather than opinions or interpretations, making it reliable for assessing the client's health status. Patient-centered data (A) refers to information focused on the client's perspective, subjective data (B) is based on the client's symptoms or feelings, and unconfirmed data (C) lacks validation or evidence, making them unreliable for making clinical decisions.

Correct Answer: A

Rationale: The correct answer is A: Immobilize the spine. This is the most appropriate intervention for a client with a suspected spinal cord injury to prevent further damage. Immobilization helps stabilize the spine and reduce the risk of spinal cord compression or injury. Administering pain relief (B) or IV fluids (C) should only be done after proper spinal immobilization to avoid exacerbating the injury. Placing the client in a supine position (D) can be beneficial if done carefully after spine immobilization, but immobilizing the spine takes precedence to prevent any potential movement that could worsen the injury.

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: A

Rationale: The correct answer is A because assessing capillary refill indicates adequate blood flow, warm toes suggest good circulation, and no discomfort indicates proper alignment and fit of the cast. Choice B is incorrect as posterior tibial pulses are not directly related to cast assessment. Choice C is incorrect as moist skin and pain threshold are not specific to cast assessment. Choice D is incorrect as discomfort of the metacarpals is not a comprehensive assessment of a cast.

Correct Answer: A

Rationale: The correct answer is A: Provide hydration. During chemotherapy, hydration is crucial to prevent dehydration and maintain kidney function. Chemotherapy drugs can be nephrotoxic and cause electrolyte imbalances. Hydration supports drug clearance and prevents kidney damage. Administering oxygen (B) is not typically a priority unless the client is experiencing respiratory distress. Administering pain medications (C) may be important but is not the priority over hydration. Monitoring for signs of infection (D) is important but providing hydration to prevent dehydration and maintain kidney function takes precedence.

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: 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: A

Rationale: The correct answer is A: Place the client on their side. This is the first nursing action for a client who develops a seizure to prevent aspiration and maintain an open airway. Placing the client on their side helps to keep their airway clear and prevents them from choking on saliva or vomit. Choice B, loosening clothing, is important but not the first priority. Choice C, placing the client in a Trendelenburg position, is not recommended as it may increase intracranial pressure. Choice D, placing the client in a sitting position, can increase the risk of injury during a seizure.