What is the most important action when caring for a client with fluid overload?

Correct Answer: A

Rationale: The correct answer is A: Monitor urine output. This is the most important action because it helps assess the client's fluid status and kidney function. Monitoring urine output can indicate if the client's body is effectively eliminating excess fluid. Elevating the head of the bed (B) helps with respiratory function but is not the priority in fluid overload. Administering diuretics (C) may be necessary but should be based on urine output monitoring. Encouraging deep breathing (D) is important for respiratory function but not directly related to managing fluid overload.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. This is the most important intervention for a client with an obstructed airway because it helps to ensure that the patient is receiving adequate oxygen supply to prevent hypoxia. Oxygen therapy can help maintain oxygen saturation levels and support proper gas exchange in the lungs. Monitoring respiratory rate (B) is important but not as critical as ensuring oxygen supply. Administering morphine (C) is contraindicated as it can depress respiratory function further. Administering fluids (D) is not the priority in managing an obstructed airway.

Correct Answer: A

Rationale: The nurse should first administer aspirin to a client with chest pain as it helps prevent blood clot formation during a possible heart attack. Aspirin inhibits platelet aggregation, reducing the risk of further blockage in the coronary arteries. Administering aspirin promptly can improve the client's outcomes. Performing an ECG, monitoring vital signs, or providing a meal plan are important but should come after administering aspirin in the initial management of chest pain to prioritize the client's safety and well-being.

Correct Answer: A

Rationale: The correct answer is A because health assessment helps establish a baseline database for comparison in future assessments, allowing for tracking of changes in health status over time. It provides essential information for identifying health issues and developing appropriate interventions. Choice B is incorrect as establishing rapport is a benefit but not the primary purpose. Choice C is incorrect as health assessment is typically conducted by primary healthcare providers, not specialists. Choice D is incorrect as quantifying pain is just one aspect of health assessment, not its primary purpose.

Correct Answer: A

Rationale: The correct answer is A, contusion. A contusion is a soft-tissue injury caused by blunt force resulting in bruising, without breaking the skin. This is different from the other choices. Strain (B) refers to an injury to a muscle or tendon due to overstretching. Sprain (C) is an injury to a ligament from overstretching. Dislocation (D) involves the displacement of bones at a joint, not a soft-tissue injury. Therefore, the term that specifically aligns with a soft-tissue injury from blunt force is contusion.

Correct Answer: D

Rationale: Step-by-step rationale for why answer D is correct: 1. Empathy and respect: By saying "I respect your decision to choose surgery," you acknowledge her autonomy and decision-making. 2. Supportive approach: This response shows understanding and non-judgmental support for her choice. 3. Person-centered care: Recognizing her individual needs and choices is crucial in providing quality healthcare. Summary: A: Irrelevant and insensitive to her medical needs. B: Disregards her current situation and overlooks the complexity of weight loss. C: Implies a one-size-fits-all approach without considering her specific circumstances. D: Demonstrates respect, understanding, and support for her decision-making.

Correct Answer: C

Rationale: Rationale: Choice C, apply ice, is the correct answer as the first intervention for a client at risk for dehydration. Applying ice helps to lower the body temperature, which can reduce sweating and fluid loss. This intervention is crucial in preventing further dehydration. Administering IV fluids (Choice A) may be necessary in severe dehydration cases, but it is not the first intervention. Administering oxygen (Choice B) is not directly related to dehydration. Elevating the leg (Choice D) is not effective in addressing dehydration. In summary, applying ice is the most appropriate initial intervention to prevent dehydration by reducing body temperature and fluid loss.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. The nurse's first action in treating hypoglycemia is to increase the client's blood glucose levels to prevent further complications. Administering glucose helps quickly raise blood sugar levels, addressing the immediate issue. Options B, C, and D are incorrect as administering insulin would further decrease blood sugar levels, administering oxygen is not the primary intervention for hypoglycemia, and administering antipyretics is used for reducing fever, not treating hypoglycemia.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. When a client with asthma develops wheezing, the primary action is to administer bronchodilators to help dilate the airways and improve breathing. This helps relieve the symptoms of wheezing and prevent further complications. Providing pain relief (Choice B) is not the primary action for wheezing in asthma. Encouraging deep breathing (Choice C) may worsen the wheezing in an asthma attack. Performing chest physiotherapy (Choice D) is not the first-line treatment for wheezing in asthma.