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: A

Rationale: The correct answer is A: Apply a sterile dressing. This is the most important intervention to prevent infection and protect the wound. Applying a sterile dressing helps maintain a clean environment, reduces the risk of contamination, and promotes wound healing. Administering fluids (B) may be necessary but is not the top priority. Administering IV antibiotics (C) may be required but is secondary to wound care. Monitoring for bleeding (D) is important but addressing the wound with a sterile dressing takes precedence to prevent infection.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. This is the priority intervention because nitroglycerin helps dilate blood vessels, reducing chest pain in clients with heart disease. It improves blood flow to the heart, relieving ischemia. Morphine (B) can mask symptoms and should be used if pain persists after nitroglycerin. Beta blockers (C) are beneficial in chronic management but not for immediate relief. Aspirin (D) helps prevent clot formation but is not the priority in acute chest pain.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. When a client presents with symptoms of hypoglycemia, the nurse should prioritize raising the blood sugar levels immediately to prevent further complications. Administering glucose helps to quickly address the low blood sugar levels and alleviate symptoms. Monitoring blood glucose (B) is important but not the first step in an acute situation. Administering insulin (C) would worsen hypoglycemia. Monitoring for arrhythmias (D) is not the primary concern when dealing with hypoglycemia.

Correct Answer: B

Rationale: Correct Answer: B (Administer nonsteroidal anti-inflammatory drugs - NSAIDs) Rationale: 1. NSAIDs are commonly used for chronic pain management due to their anti-inflammatory properties. 2. NSAIDs target the underlying inflammation that often contributes to chronic pain. 3. Opioids may be reserved for severe pain due to their potential for addiction and side effects. 4. Monitoring blood pressure is important but not the primary intervention for chronic pain. 5. Acetaminophen is a mild pain reliever and may not be as effective for chronic pain compared to NSAIDs.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates cultural competence and respect for the patient's beliefs. It shows willingness to accommodate the patient's request, promoting trust and effective communication. Choice B is incorrect as it dismisses the patient's request and may lead to distrust. Choice C is incorrect as it disregards the patient's cultural beliefs and can be perceived as insensitive. Choice D is incorrect as it invalidates the patient's beliefs and can hinder the therapeutic relationship. Ultimately, choice A is the most appropriate response to promote patient-centered care and build a trusting relationship with the patient.

Correct Answer: C

Rationale: The primary purpose of an abdominal binder after surgery is to increase circulation. An abdominal binder helps improve blood flow to the surgical site, which can aid in reducing swelling, promoting healing, and preventing complications such as blood clots. It provides gentle compression to support the abdominal muscles and tissues without restricting circulation. Choice A (Promote comfort) is incorrect because while an abdominal binder may provide some comfort by supporting the abdomen, its primary purpose is not solely for comfort. Choice B (Prevent infection) is incorrect because an abdominal binder does not directly prevent infection. Infection prevention is primarily achieved through proper wound care and infection control practices. Choice D (Provide wound care) is incorrect because an abdominal binder does not provide wound care. Wound care involves cleaning, dressing changes, and monitoring for signs of infection, which are separate from the purpose of an abdominal binder.

Correct Answer: A

Rationale: The correct answer is A: Light therapy. Light therapy is effective for treating sleep problems, stress, and seasonal affective disorders because exposure to bright light can regulate circadian rhythms, improve mood, and alleviate symptoms associated with these conditions. Light therapy helps reset the body's internal clock, promoting better sleep patterns and reducing stress. Exercise (choice B) can also improve sleep and reduce stress, but it may not specifically target seasonal affective disorders. Medication (choice C) and herbal treatments (choice D) are not typically recommended as the first-line treatment for these conditions and may have side effects or limited efficacy compared to light therapy.

Correct Answer: A

Rationale: The correct answer is A: Administer antihypertensive medication. In a hypertensive emergency, the priority is to lower blood pressure quickly to prevent organ damage. Antihypertensive medications like nitroprusside or labetalol are used for this purpose. Placing the client in a comfortable position and administering oxygen (B) may be beneficial, but lowering the blood pressure is the primary action. Monitoring blood pressure and administering antihypertensive medication (C) is correct, but the emphasis should be on immediate intervention. Monitoring the client's ECG (D) is important but not the primary action in a hypertensive emergency.