What is the primary action when a client with a history of asthma develops wheezing?

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. When a client with asthma develops wheezing, the primary action is to administer bronchodilators to help dilate the airways and improve breathing. This helps relieve the symptoms of wheezing and prevent further complications. Providing pain relief (Choice B) is not the primary action for wheezing in asthma. Encouraging deep breathing (Choice C) may worsen the wheezing in an asthma attack. Performing chest physiotherapy (Choice D) is not the first-line treatment for wheezing in asthma.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. When a client with asthma develops wheezing, the primary action is to administer bronchodilators to help dilate the airways and improve breathing. This helps relieve the symptoms of wheezing and prevent further complications. Providing pain relief (Choice B) is not the primary action for wheezing in asthma. Encouraging deep breathing (Choice C) may worsen the wheezing in an asthma attack. Performing chest physiotherapy (Choice D) is not the first-line treatment for wheezing in asthma.

Correct Answer: B

Rationale: The correct answer is B: Purchase absorbent undergarments. For stress incontinence, which is caused by weakened pelvic floor muscles, absorbent undergarments can help manage symptoms. Kegel exercises (choice A) strengthen pelvic floor muscles but may not provide immediate relief. Constipation (choice C) can exacerbate incontinence but is not the primary intervention. Surgical treatments (choice D) are not typically recommended as a first-line intervention for stress incontinence.

Correct Answer: A

Rationale: The correct answer is A because health assessment helps establish a baseline database for comparison in future assessments, allowing for tracking of changes in health status over time. It provides essential information for identifying health issues and developing appropriate interventions. Choice B is incorrect as establishing rapport is a benefit but not the primary purpose. Choice C is incorrect as health assessment is typically conducted by primary healthcare providers, not specialists. Choice D is incorrect as quantifying pain is just one aspect of health assessment, not its primary purpose.

Correct Answer: A

Rationale: The correct answer is A: Assess airway. In caring for a client with a traumatic head injury, the first priority is to ensure there is a clear airway to maintain oxygenation and ventilation, which is crucial for brain function. If the airway is compromised, it can lead to hypoxia and further brain damage. Providing pain relief (B) is important but not the immediate priority. Monitoring intracranial pressure (C) is essential but comes after ensuring a patent airway. Maintaining a quiet environment (D) can help reduce stimulation, but it is not as critical as assessing the airway for immediate intervention.

Correct Answer: A

Rationale: The correct answer is A: Reorient the client. This is the first step because confusion post-operatively could be due to anesthesia, pain medications, or disorientation. Reorienting the client helps bring them back to reality and decrease anxiety. B: Monitoring for signs of infection would be important but not the initial step for confusion. C: Monitoring serum electrolytes is important but not the immediate priority for confusion. D: Applying a cold compress is not relevant for confusion in a post-operative client.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In hypovolemic shock, the body lacks adequate circulating blood volume leading to decreased tissue perfusion and oxygen delivery. Administering oxygen helps increase oxygen saturation levels and improve tissue oxygenation. This is the priority nursing action to ensure the client's vital organs receive sufficient oxygen. Administering pain relief (B) may be necessary but is not the priority in hypovolemic shock. Administering beta blockers (C) can further decrease blood pressure and worsen the condition. Monitoring for bleeding (D) is important, but administering oxygen takes precedence to address the immediate oxygenation needs of the client.

Correct Answer: A

Rationale: The correct answer is A: coma. High ammonia levels can lead to hepatic encephalopathy, causing impaired brain function and potentially leading to coma. Edema (B) is typically associated with fluid retention, not high ammonia levels. Hypoxia (C) is a condition of low oxygen levels, not directly related to high ammonia levels. Polyuria (D) is excessive urination, which is not a common sign of high ammonia levels.

Correct Answer: A

Rationale: The correct answer is A: Administer pain relief. This is the priority action because managing pain is crucial in providing comfort and reducing distress for the client with a severe burn. Pain relief helps in improving the client's overall well-being and promotes better recovery. Administering corticosteroids (Choice B) is not the priority as pain relief takes precedence. Monitoring for infection (Choice C) is important but not the immediate priority. Applying dressings (Choice D) is also important but should come after administering pain relief.