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: 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: D

Rationale: The correct answer is D: Administer morphine. Administering morphine is the first intervention for a client experiencing a myocardial infarction (MI) to help relieve pain and reduce anxiety. Oxygen may not be necessary if the client is not hypoxic. Administering aspirin is important but usually follows morphine. Monitoring ECG is crucial, but not the first intervention to address the immediate symptoms of MI.

Correct Answer: B

Rationale: The correct answer is B: Vitamin B12. Strict vegetarians, especially those who exclude all animal products, are at risk of Vitamin B12 deficiency as it is primarily found in animal products. Vitamin C (A) deficiency is more common in those with poor fruit and vegetable intake. Vitamin E (C) deficiency is rare and usually seen in individuals with specific medical conditions. Magnesium (D) deficiency can occur in individuals with poor dietary intake or certain medical conditions, but it is not the primary concern for strict vegetarians.

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: 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: Assess vital signs. This is the first intervention because it provides immediate information on the client's condition and helps determine the severity of the pain. Monitoring vital signs can reveal signs of shock, dehydration, or other serious complications. Performing a CT scan (B) is not the first priority as it requires time and resources. Monitoring urine output (C) may be important but not as immediate as assessing vital signs. Monitoring for signs of shock (D) can be included in assessing vital signs but is not the primary intervention.

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.

Correct Answer: C

Rationale: Rationale: Choice C, apply ice, is the correct answer as the first intervention for a client at risk for dehydration. Applying ice helps to lower the body temperature, which can reduce sweating and fluid loss. This intervention is crucial in preventing further dehydration. Administering IV fluids (Choice A) may be necessary in severe dehydration cases, but it is not the first intervention. Administering oxygen (Choice B) is not directly related to dehydration. Elevating the leg (Choice D) is not effective in addressing dehydration. In summary, applying ice is the most appropriate initial intervention to prevent dehydration by reducing body temperature and fluid loss.