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: Administer oxygen. The first action should be to ensure the client's oxygenation as chest pain could indicate decreased oxygen supply. Administering oxygen helps improve oxygen levels and can be crucial in managing potential complications. Summary of other choices: B: Administering morphine may mask the pain but doesn't address the underlying issue. C: Administering anticoagulants is not appropriate as the cause of chest pain is not related to clotting. D: Applying a warm compress is not indicated and may delay proper assessment and intervention for the chest pain.

Correct Answer: A

Rationale: The correct answer is A: Shortness of breath and weight gain. In chronic heart failure, fluid overload can lead to pulmonary congestion, causing shortness of breath. Weight gain is also a key sign of fluid retention. Increased urine output and hypotension (choice B) are more indicative of dehydration. Fatigue and dizziness (choice C) can be nonspecific symptoms and not directly related to fluid overload. Dry mouth and thirst (choice D) are symptoms of dehydration rather than fluid overload in chronic heart failure. Monitoring for shortness of breath and weight gain allows for early detection and intervention in managing fluid overload in patients with chronic heart failure.

Correct Answer: A

Rationale: Step-by-step rationale: 1. High HDL cholesterol is associated with decreased cardiovascular disease risk. 2. HDL cholesterol helps remove LDL cholesterol from arteries, reducing plaque buildup. 3. This leads to lower risk of heart disease and stroke. 4. Low HDL cholesterol (choice B) is associated with increased risk. 5. Low total cholesterol (choice C) and low triglycerides (choice D) do not directly correlate with decreased cardiovascular disease risk. Summary: High HDL cholesterol is beneficial for cardiovascular health as it helps reduce plaque buildup in arteries. Low HDL cholesterol, low total cholesterol, and low triglycerides are not associated with decreased cardiovascular disease risk.

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: D

Rationale: I must correct you on this question. The correct answer for the most appropriate action for a nurse to take when a client develops a deep vein thrombosis (DVT) is not D. The correct answer should be C: Provide anticoagulant therapy. Anticoagulant therapy is the standard treatment for DVT to prevent the blood clot from getting larger and to reduce the risk of it breaking loose and causing a pulmonary embolism. Elevating the leg and applying compression can help with symptoms but are not the primary treatment for DVT. Massage is contraindicated as it can dislodge the blood clot.

Correct Answer: C

Rationale: The correct answer is C. Patients with cirrhosis should limit protein intake to prevent hepatic encephalopathy. Statement C indicates a need for further education as it is incorrect. A is correct as alcohol worsens cirrhosis. B is correct to manage symptoms. D is correct to monitor for fluid retention.

Correct Answer: B

Rationale: Step 1: Patient stating they can stop taking medication once BP is normal shows misunderstanding of hypertension as a chronic condition. Step 2: Hypertension requires long-term management even if BP is controlled temporarily. Step 3: Stopping medication abruptly can lead to BP spikes and complications. Step 4: Other choices (A, C, D) demonstrate good understanding and proactive approach to managing hypertension. Summary: Choice B is incorrect as it suggests discontinuation of medication, posing a risk to the patient's health. Choices A, C, and D show positive behaviors towards hypertension management.

Correct Answer: A

Rationale: Step 1: Cirrhosis can impair the liver's ability to store glycogen and produce glucose. Step 2: Liver dysfunction can lead to hypoglycemia due to decreased glycogen stores and gluconeogenesis. Step 3: Monitoring for hypoglycemia is crucial as it can result in serious complications. Step 4: Hyperglycemia (B) is less likely in cirrhosis as the liver's ability to regulate blood sugar is impaired. Step 5: Hypokalemia (C) and hyperkalemia (D) are less directly related to cirrhosis and are not the primary concerns in this case.