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: C

Rationale: The correct answer is C: Ensure the lens is centered on the cornea. This is important because removing a hard contact lens that is not centered can cause damage to the cornea or surrounding structures. By ensuring the lens is properly positioned on the cornea before attempting removal, the risk of injury is minimized. Explanation of other choices: A: Gently irrigating the eye with solution is not the correct procedure for removing hard contact lenses as it does not address the specific task of lens removal. B: Grasping the lens with a gentle pinching motion can be harmful if the lens is not centered, leading to potential damage to the eye. D: Using sterile gloves before attempting removal is important for hygiene but does not directly affect the safe removal of hard contact lenses from an unresponsive client.

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: B

Rationale: The correct answer is B: increased fibrinogen. In DIC, there is consumption of coagulation factors leading to decreased fibrinogen levels. Heparin therapy helps by inhibiting further thrombus formation, allowing the body to replenish fibrinogen levels. Increased fibrinogen indicates a positive response. Incorrect choices: A) increased platelet count is not specific to Heparin therapy in DIC, C) decreased fibrin split products indicate ongoing coagulation, not a positive response, and D) decreased bleeding is a general response and not specific to Heparin therapy in DIC.

Correct Answer: B

Rationale: Correct Answer: B - Administer oxygen Rationale: 1. Oxygen therapy is crucial in managing COPD exacerbation to improve oxygen saturation levels. 2. Adequate oxygenation is essential to prevent further respiratory distress and potential complications. 3. Oxygen therapy helps alleviate symptoms like shortness of breath and fatigue, improving overall comfort. 4. Monitoring oxygen saturation levels guides the effectiveness of treatment and ensures appropriate oxygen delivery. Summary: - Administering corticosteroids (A) may help reduce inflammation in COPD exacerbation but does not address the immediate need for oxygen. - Monitoring respiratory rate (C) is important but prioritizing oxygen administration is more critical for immediate respiratory support. - Administering diuretics (D) may be indicated in certain cases of COPD exacerbation with fluid retention but is not the priority over oxygen therapy.

Correct Answer: D

Rationale: The correct answer is D: Administer diuretics. The priority for a nurse caring for a client with pneumonia is to maintain adequate oxygenation and prevent respiratory failure. Diuretics help reduce fluid overload in the lungs, improving gas exchange and oxygenation. Administering antibiotics (choice A) is important to treat the infection but not the top priority. Administering oxygen (choice B) is crucial for oxygenation, but diuretics take precedence to improve lung function. Administering corticosteroids (choice C) may be considered in certain cases to reduce inflammation, but it is not the primary priority.

Correct Answer: A

Rationale: The correct answer is A: Open the airway. This is the first intervention because ensuring a clear airway is crucial for adequate oxygenation. If the airway is obstructed, oxygen administered or suctioning performed may not be effective. Checking for breathing should follow airway opening. Administering oxygen can be done once the airway is established. Suctioning is not the priority unless there is evidence of airway obstruction.

Correct Answer: D

Rationale: The correct answer is D (Morton's neuroma) because interventions for difficulty walking due to a foot mass include recommending proper footwear, orthotic devices, corticosteroid injections, physical therapy, and in severe cases, surgical removal of the mass. Morton's neuroma causes pain and tingling in the ball of the foot, leading to difficulty walking. Plantar fasciitis (A), Hallux valgus (B), and Hammertoe (C) do not typically present with a mass in the foot causing difficulty walking.

Correct Answer: B

Rationale: The correct answer is B: Place in a safe environment. This is the first priority to ensure the safety of the confused post-operative client. Placing the client in a safe environment prevents harm from falls or accidents. Reorienting the client (choice A) can come after ensuring safety. Administering pain relief (choices C and D) should be done based on assessment but is not the first priority when the client is confused.