What is the most important intervention for a client in shock?

Correct Answer: A

Rationale: The correct answer is A: Administer fluids. In shock, the most crucial intervention is to restore perfusion by increasing circulating volume. Administering fluids helps to improve tissue perfusion and oxygen delivery. This is essential for stabilizing the client's condition. Monitoring cardiac rhythm (B) and blood pressure (C) are important, but addressing the underlying issue of hypovolemia by giving fluids takes precedence. Providing IV antibiotics (D) is not the primary intervention for shock, as the immediate focus should be on restoring blood flow and oxygen delivery.

Correct Answer: B

Rationale: The correct answer is B because the Set Test typically involves naming 10 items based on specific categories, such as those in the FACT acronym (Fruit, Animal, Color, and Town). The nurse should inform Mr. C. that he can complete the task without any hurry, which helps reduce stress and allows him to focus on recalling the items. This approach aligns with the standard administration procedure of the Set Test, promoting a relaxed and supportive environment for the patient. Choice A is incorrect because the nurse should not offer direct assistance or mention availability to help unless Mr. C. explicitly requests it. Choice C is incorrect as prompting the patient's memory may interfere with the natural cognitive process being assessed. Choice D is incorrect because imposing a time limit can induce unnecessary pressure and potentially affect the accuracy of the results.

Correct Answer: A

Rationale: The correct answer is A: Perform a lumbar puncture. This is the first action because diagnosing meningitis requires cerebrospinal fluid analysis obtained through a lumbar puncture. It helps identify the specific type of meningitis (bacterial, viral, or fungal) and guides appropriate treatment. Administering pain relief (B) or oxygen (C) may be necessary but not the initial priority. Administering antibiotics (D) should be based on the results of the lumbar puncture to ensure targeted therapy.

Correct Answer: C

Rationale: The most important goal for a nurse when implementing care for a patient with a chronic illness is to prevent future complications (Choice C). This is because chronic illnesses are long-term conditions that require ongoing management to minimize the risk of complications and improve the patient's quality of life. By preventing future complications, the nurse helps maintain the patient's health and prevents the progression of the disease. Providing emotional support (Choice D) is important but not the most crucial goal in this context. While reducing symptoms (Choice B) is important, preventing future complications takes precedence as it addresses the underlying cause of the illness. Curing the disease (Choice A) may not always be feasible for chronic illnesses, making prevention of complications a more realistic and essential goal.

Correct Answer: C

Rationale: The correct answer is C: Severity. In the PQRSTU mnemonic, "S" stands for Severity, which refers to the intensity or seriousness of the symptoms experienced by the patient. This is crucial in assessing the impact of the problem on the patient's health and well-being. Incorrect choices: A: Swelling - Swelling is a physical symptom and does not encompass all aspects of the patient's perception. B: Subjectivity - While the patient's subjective experience is important, it does not specifically refer to severity. D: Symptoms - While symptoms are part of the patient's perception, the "S" in PQRSTU specifically focuses on the severity of those symptoms.

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: Breath sounds and oxygen saturation. In COPD, monitoring respiratory status is crucial due to impaired gas exchange. Assessing breath sounds helps identify any adventitious sounds like wheezing or crackles, indicating respiratory distress. Oxygen saturation reflects oxygenation status, vital for patients with COPD prone to hypoxemia. Nutritional intake and weight (B), bowel sounds and abdominal girth (C), and urine output and skin integrity (D) are important but secondary assessments in this case. Nutritional status and weight are important for overall health, bowel sounds and abdominal girth are related to gastrointestinal function, and urine output and skin integrity are indicators of hydration and overall skin health, respectively. However, in a patient with COPD, the priority is ensuring adequate oxygenation and respiratory function.

Correct Answer: B

Rationale: The correct answer is B: Administer antibiotics. In sepsis, timely administration of antibiotics is crucial to combat the underlying infection. Antibiotics target the bacteria causing the sepsis, helping to prevent further spread and worsening of the condition. Administering IV fluids (choice A) is important to maintain blood pressure, but antibiotics take precedence in treating the infection. Providing fluids (choice C) is also important but not the priority over antibiotics. Administering oxygen (choice D) may be necessary for respiratory support in severe cases of sepsis, but it does not address the root cause of the condition like antibiotics do.

Correct Answer: A

Rationale: The correct answer is A because it focuses on prioritizing the assessment by first addressing the immediate problem of shortness of breath. By examining only the body areas related to the current issue, the nurse can quickly gather essential information to manage the patient's respiratory distress effectively. Once the critical issue is stabilized, a complete assessment can be conducted to identify any underlying problems or potential complications. This approach ensures that the nurse addresses the most urgent needs first before proceeding to a comprehensive assessment. Choice B is incorrect because it suggests only examining body areas directly related to the hospitalization problem, which may overlook other critical issues contributing to the shortness of breath. Choice C is incorrect as shortness of breath is not a normal finding and should not be dismissed without further evaluation. Choice D is incorrect as examining the entire body without focusing on the immediate issue may delay appropriate interventions for the patient's respiratory distress.