What is the priority intervention when a client is experiencing respiratory distress?

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. When a client is experiencing respiratory distress, the priority intervention is to open up the airways to improve breathing. Bronchodilators help relax and widen the airways, making it easier for the client to breathe. This intervention addresses the immediate need for improved respiratory function. Administering corticosteroids (choices B and C) may be beneficial in some cases but is not the priority in acute respiratory distress. Monitoring respiratory rate (choice D) is important but does not directly address the underlying issue of airway constriction in respiratory distress.

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: 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: D

Rationale: The correct answer is D: provide culturally sensitive and appropriate care. Including cultural information in the health assessment helps healthcare providers understand the patient's beliefs, practices, and preferences, allowing for tailored care that respects the patient's cultural background. This improves communication, trust, and overall health outcomes. Choice A is incorrect because cultural information does not necessarily identify the cause of an illness. Choice B is incorrect as it overemphasizes diagnosis without considering the patient's cultural context. Choice C is incorrect as it does not directly address the importance of cultural information in healthcare.

Correct Answer: C

Rationale: The correct answer is C because monitoring kidney function with regular laboratory tests is crucial in managing CKD. Regular testing helps identify changes in kidney function early, allowing for timely interventions to prevent complications. Administering diuretics (choice A) may worsen kidney function. Encouraging weight loss (choice B) may be necessary, but monitoring kidney function takes precedence. Encouraging the patient to limit fluid intake (choice D) may be necessary in some cases, but it is not the priority intervention.

Correct Answer: B

Rationale: The correct answer is B: Increased shortness of breath. During a COPD exacerbation, airflow limitation worsens, leading to increased difficulty in breathing. This is a common sign due to air trapping and inflammation in the airways. Sudden weight gain (A) is not typically associated with COPD exacerbation. Decreased heart rate (C) is not a common sign and is more likely to occur in other conditions. Increased energy levels (D) are unlikely during a COPD exacerbation as the body is under stress from impaired lung function.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and vascular damage. Monitoring for DVT is crucial to prevent life-threatening complications like pulmonary embolism. Acute renal failure (A) is not directly related to stroke and is not a common complication. Pneumonia (C) may occur but is not the highest priority compared to DVT. Hypertension (D) is important to monitor but is not the priority in this case as DVT poses a more immediate risk to the patient's health.

Correct Answer: B

Rationale: The correct answer is B: "Is there anything else you would like to mention?" This question allows the patient to share any additional information or concerns before concluding the interview. It shows empathy and ensures thorough communication. Choice A is not the best option as it may suggest the nurse is rushing or has overlooked something. Choice C is inappropriate as it lacks empathy and may make the patient feel rushed. Choice D is also incorrect as it shifts the focus to a different topic instead of allowing the patient to express any remaining issues or questions.

Correct Answer: B

Rationale: The correct answer is B: Encourage fluid intake. Adequate hydration helps in pain management by promoting circulation and reducing inflammation. Opioids (choice A) should only be used if non-pharmacological interventions fail. Administering oxygen (choice C) is not typically indicated for pain management. Monitoring electrolyte levels (choice D) is important but not the most immediate intervention for acute pain post-surgery.