What is the priority nursing intervention for a client with shortness of breath and wheezing?

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help dilate the airways, relieving bronchospasm and improving airflow in clients experiencing shortness of breath and wheezing. This intervention directly addresses the underlying cause of the symptoms. Administering corticosteroids (B) may be considered in severe cases to reduce inflammation but is not the priority initial intervention. Administering pain relief (C) is not indicated unless pain is identified as a contributing factor. Placing the client in a sitting position (D) can help improve breathing but does not directly address the bronchoconstriction causing the wheezing.

Correct Answer: D

Rationale: The correct answer is D: To treat human responses. This goal aligns with the nursing profession's focus on addressing the holistic needs of individuals. Nurses aim to understand and manage patients' emotional, physical, and psychological responses to illness or treatment. By treating human responses, nurses can improve overall well-being. A: Providing cost-effective care is important but not a broad goal within nursing. It is a component of efficient healthcare delivery. B: Forming broad nursing diagnoses is a part of the nursing process, not a broad goal in itself. C: Promoting self-care is crucial in nursing practice, but it is more of a specific intervention rather than a broad goal encompassing the entire profession.

Correct Answer: B

Rationale: The correct answer is B: Provide IV fluids. The first step in caring for a client with severe burn injuries is to ensure adequate hydration and prevent hypovolemic shock. IV fluids are crucial to replace lost fluids and maintain circulation. Cooling the burn site (choice A) may be important but not the first step. Providing pain relief (choice C) is important but not as critical initially. Initiating IV fluids (choice D) is similar to the correct answer, but providing IV fluids is more urgent than initiating them.

Correct Answer: A

Rationale: The correct answer is A. Assessing serum creatinine levels and GFR is crucial in monitoring kidney function in CKD patients. These tests provide information on the kidney's ability to filter waste products from the blood. Monitoring these levels helps in determining the stage of CKD and adjusting treatment plans accordingly. Blood glucose levels (B) are important in diabetes management but not the priority in CKD. Hemoglobin levels (C) are important for anemia assessment in CKD but not as critical as kidney function. Potassium levels (D) are important to monitor in CKD, but assessing kidney function takes precedence.

Correct Answer: B

Rationale: The correct answer is B: Place the client in a supine position. This is the first step when administering Heparin to prevent bleeding or bruising at the injection site. Placing the client in a supine position helps reduce the risk of injury and promotes optimal absorption. Administering antipyretics (Choice A) is not the first step in administering Heparin. Administering insulin (Choice C) is unrelated to Heparin administration. Monitoring vital signs (Choice D) is important but typically done after the initial step of positioning the client correctly.

Correct Answer: D

Rationale: Step 1: Establish rapport by showing interest in the patient's well-being. Step 2: Emphasize continuity of care by referencing the previous visit. Step 3: Encourage open communication about any changes or concerns. Step 4: Initiate discussion on the patient's health status since the last visit. Summary: A - Too broad and not focused on the patient's own health. B - Assumes the patient has a specific reason for the visit. C - Assumes the patient has hypertension and may not be relevant. D - Encourages discussion on the patient's health status and continuity of care.

Correct Answer: B

Rationale: The correct answer is B: not pulling to a standing position. In an 11-12-month-old child, the inability to pull to a standing position may indicate developmental dysplasia of the hip (DDH) as it can lead to abnormal hip development. Refusal to walk (A) can be a sign of other musculoskeletal issues but not specific to DDH. Negative Trendelenburg sign (C) refers to weakness in the hip abductors and is not a specific finding for DDH. A negative Ortolani sign (D) indicates the absence of hip dislocation and is not a definitive sign of DDH at this age.

Correct Answer: B

Rationale: The correct answer is B because taking insulin only when blood sugar is high is incorrect and can lead to dangerous complications. Step 1: Insulin should be taken as prescribed by the healthcare provider, not based solely on blood sugar levels. Step 2: Checking blood sugar regularly (A) is essential for diabetes management. Step 3: Eating a balanced diet and exercising regularly (C) are crucial for diabetes control. Step 4: Reporting signs of infection to the healthcare provider (D) is important due to diabetes-related complications.

Correct Answer: A

Rationale: The correct answer is A: Body systems. This type of assessment promotes critical thinking by organizing data systematically based on different body systems, allowing for clustering of similar data and identification of patterns. Comprehensive assessments (B) may include body systems but lack the focused approach of promoting critical thinking. Head to toe assessments (C) are systematic but may not encourage clustering of data. Emergency assessments (D) prioritize immediate interventions rather than promoting critical thinking or clustering of data.