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.

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: C

Rationale: The correct answer is C: Critical thinking. Critical thinking involves analyzing information, evaluating options, and making sound decisions. When caring for multiple clients with complex care, critical thinking enables nurses to prioritize tasks, anticipate complications, and adapt care plans accordingly. Diagnostic reasoning (A) is important but focuses on identifying specific health issues. Physical assessment (B) is crucial but only addresses one aspect of care. Nursing care plans (D) are essential tools but rely on critical thinking for effective implementation. In conclusion, critical thinking is the key as it encompasses all aspects of problem-solving in complex care situations.

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: A

Rationale: The correct answer is A because using the defrost setting on microwave ovens can help safely heat breast milk or formula for the infant without compromising its quality. This method ensures that the milk is heated evenly and prevents hot spots that could burn the baby's mouth. Choice B is incorrect because refrigerating partially used bottles can lead to bacterial growth and contamination. Choice C is incorrect as mixing water and concentrate in different ratios can result in either too diluted or too concentrated formula, which can be harmful to the infant. Choice D is incorrect as adding new formula to partially used bottles can also lead to bacterial growth and spoilage.