What is the priority nursing action for a client with suspected hypovolemic shock?

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: 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: B

Rationale: Rationale: 1. pH within normal range (7.35-7.45) indicates homeostasis. 2. PO2 (normal 75-100 mmHg) and PCO2 (normal 35-45 mmHg) are slightly deviated but not clinically significant. 3. HCO3 within normal range (22-26 mEq/L) further supports overall balance. Summary: A: Incorrect - HCO3 level is within normal range, ruling out metabolic alkalosis. C: Incorrect - PCO2 is within normal range, ruling out respiratory acidosis. D: Incorrect - PCO2 is slightly low but not significantly, ruling out respiratory alkalosis. Overall, the ABG values indicate the body is in homeostasis.

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: 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: In emergency situations, time is crucial. Emergency assessment is the most appropriate as it focuses on quickly identifying and addressing life-threatening issues. It involves a rapid but systematic evaluation of the patient's airway, breathing, circulation, and disability. Head-to-toe assessment (A) and comprehensive assessment (C) are too time-consuming in emergencies, whereas focused assessment (B) may not cover all critical aspects.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for an allergic reaction as it helps to reverse severe symptoms like swelling, difficulty breathing, and low blood pressure. Administering epinephrine promptly can prevent the allergic reaction from escalating into a life-threatening situation. Antihistamines (choice B) may be given after epinephrine for symptom relief but are not as immediate in action. Monitoring vital signs (choice C) is important, but administering epinephrine takes precedence in managing the allergic reaction. Providing a cold compress (choice D) may help with local swelling but does not address the systemic effects of the allergic reaction.

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.

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.