What is the priority intervention for a client who is experiencing an acute asthma attack?

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. During an acute asthma attack, the priority intervention is to immediately open the airways to improve breathing. Bronchodilators, such as albuterol, work rapidly to dilate the bronchioles and relieve bronchospasms, making it the most effective initial treatment. Corticosteroids (B) are used for long-term control, not immediate relief. Applying oxygen and administering albuterol (C) is close, but bronchodilators should be given first for quicker relief. Applying a cold compress (D) is not appropriate for managing an asthma attack.

Correct Answer: A

Rationale: The correct answer is A: Monitor aPTT levels. This is crucial in intravenous heparin therapy to ensure the therapeutic range is maintained for anticoagulation without causing bleeding. Monitoring aPTT helps adjust heparin dosage to prevent clot formation or excessive bleeding. B: Monitoring for bleeding is important but not the most important action compared to monitoring aPTT levels for appropriate dosing. C: Checking platelet count is important for some anticoagulants like heparin, but aPTT monitoring is more directly related to heparin's anticoagulant effect. D: Administering a heparin antidote (protamine sulfate) is necessary in case of heparin overdose or in emergency situations but is not the primary action in routine care.

Correct Answer: D

Rationale: The correct answer is D because when a client experiences an allergic reaction to a medication, the nurse should monitor for signs of infection as allergic reactions can sometimes lead to secondary infections. By closely monitoring the client for signs of infection, the nurse can promptly intervene and provide appropriate treatment. A: Discontinuing the medication is important but not the immediate priority when dealing with an allergic reaction. B: Notifying the healthcare provider is important, but monitoring for signs of infection takes precedence in this situation. C: Administering antihistamines may help with allergic symptoms but does not address the potential risk of secondary infection.

Correct Answer: B

Rationale: The correct answer is B: Apply sterile dressings. This is the priority nursing intervention for a client with a deep wound infection because it helps prevent further contamination and promotes wound healing. Sterile dressings create a barrier against external pathogens and keep the wound environment clean, which is crucial in managing infections. Administering IV antibiotics (choice A) may be necessary but treating the wound first is essential. Applying heat to the wound (choice C) can worsen the infection by promoting bacterial growth. Administering IV fluids (choice D) may be needed for hydration but is not the priority in managing a deep wound infection.

Correct Answer: A

Rationale: The correct action is to administer IV fluids when a client's blood pressure drops significantly. This helps increase blood volume and improve circulation, stabilizing the blood pressure. Administering pain medication (B) does not address the root cause of low blood pressure. Applying a heating pad (C) is not effective in treating low blood pressure. Monitoring the client's respiratory rate (D) is important but not the immediate action needed to address a significant drop in blood pressure.

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: B

Rationale: The correct answer is B: Increase weight. For a client at risk for nutritional problems, increasing weight is crucial to improve overall health and address potential malnutrition. This goal focuses on restoring and maintaining a healthy weight, which is essential for proper functioning of the body and reducing the risk of various health issues. Promoting healthy nutritional practices (choice A) is important but may not address the immediate need for weight gain. Treating complications of malnutrition (choice C) is reactive rather than proactive. Increasing protein in the diet (choice D) is helpful but not comprehensive enough to address the overall nutritional needs of the client.

Correct Answer: B

Rationale: Correct Answer: B - Administer oxygen Rationale: 1. Oxygen therapy is crucial in managing COPD exacerbation to improve oxygen saturation levels. 2. Adequate oxygenation is essential to prevent further respiratory distress and potential complications. 3. Oxygen therapy helps alleviate symptoms like shortness of breath and fatigue, improving overall comfort. 4. Monitoring oxygen saturation levels guides the effectiveness of treatment and ensures appropriate oxygen delivery. Summary: - Administering corticosteroids (A) may help reduce inflammation in COPD exacerbation but does not address the immediate need for oxygen. - Monitoring respiratory rate (C) is important but prioritizing oxygen administration is more critical for immediate respiratory support. - Administering diuretics (D) may be indicated in certain cases of COPD exacerbation with fluid retention but is not the priority over oxygen therapy.

Correct Answer: A

Rationale: The correct answer is A, contusion. A contusion is a soft-tissue injury caused by blunt force resulting in bruising, without breaking the skin. This is different from the other choices. Strain (B) refers to an injury to a muscle or tendon due to overstretching. Sprain (C) is an injury to a ligament from overstretching. Dislocation (D) involves the displacement of bones at a joint, not a soft-tissue injury. Therefore, the term that specifically aligns with a soft-tissue injury from blunt force is contusion.