What is the priority nursing intervention for a client with severe dehydration?

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. This is the priority intervention because severe dehydration requires immediate fluid replacement to restore fluid balance and prevent further complications. IV fluids are the most rapid and effective way to rehydrate a severely dehydrated client. Monitoring vital signs (B) and blood pressure (D) are important, but administering IV fluids takes precedence. Encouraging oral fluids (C) may not be sufficient for a client with severe dehydration who may not be able to adequately absorb fluids orally.

Correct Answer: B

Rationale: The correct answer is B because cleansing and dressing the wound is crucial in preventing further infection spread. First, cleansing the wound removes debris and pathogens, reducing the risk of infection. Second, dressing the wound protects it from external contaminants. This proactive approach promotes wound healing and prevents complications. A: Notifying the healthcare provider is important, but immediate wound care should be prioritized. C: Applying a dressing without cleansing the wound first may trap bacteria and worsen the infection. D: Pain medications are important for client comfort, but addressing the infection source is necessary for proper healing.

Correct Answer: B

Rationale: The correct answer is B: Provide a source of fast-acting carbohydrate. This is because in hypoglycemia, the patient's blood sugar levels are low and need to be raised quickly to avoid serious complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (choice A) would further lower blood sugar levels, monitoring without intervention (choice C) could lead to worsening symptoms, and administering an oral hypoglycemic agent (choice D) may not act quickly enough to raise blood sugar levels in an emergency situation.

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.

Correct Answer: A

Rationale: The correct answer is A: Administer pain relief. This is the priority nursing action for a client with an electrical burn because pain management is crucial in providing comfort and reducing distress. Pain relief helps the client to relax, promotes healing, and aids in overall recovery. Administering pain relief should be the first step to ensure the client's well-being. Summary: - B: Administering oxygen may be necessary for respiratory support in some cases but is not the priority over pain relief. - C: Applying sterile dressings is important for wound care but should come after addressing pain. - D: Administering beta blockers is not indicated as the priority action for an electrical burn.

Correct Answer: A

Rationale: The correct answer is A: Neutropenia. Neutropenia is a common side effect of chemotherapy where there is a decrease in neutrophil count, increasing the risk of infections. Monitoring for neutropenia is crucial to prevent serious infections and sepsis in chemotherapy patients. Hyperkalemia (B), chronic pain (C), and hypertension (D) are not direct complications of chemotherapy and do not pose immediate life-threatening risks to patients undergoing chemotherapy. Monitoring for neutropenia takes precedence due to the potential for life-threatening infections in immunocompromised patients.

Correct Answer: A

Rationale: The correct answer is A: Administering diuretics to manage fluid retention. In heart failure, fluid overload can worsen symptoms and lead to complications. Diuretics help reduce excess fluid in the body, relieving strain on the heart. This intervention helps improve cardiac function and alleviate symptoms. Choice B (Encouraging increased physical activity) may be beneficial in some cases, but in heart failure, excessive physical activity can strain the heart further. Choice C (Providing a low-sodium diet) is important in managing heart failure, but diuretics would be more critical initially to address immediate fluid retention. Choice D (Encouraging high-potassium foods) is important for overall health but not the priority in managing heart failure.

Correct Answer: B

Rationale: The correct answer is B: Shakiness and dizziness. Hypoglycemia is characterized by low blood sugar levels, leading to symptoms such as shakiness and dizziness. This is because the brain requires glucose for energy, and when levels drop too low, these symptoms can occur. Increased thirst and urination (A) are more indicative of hyperglycemia, where blood sugar levels are too high. Blurred vision and headaches (C) can be symptoms of both hyperglycemia and hypoglycemia but are less specific to hypoglycemia. Fatigue and weight loss (D) are not typical symptoms of hypoglycemia.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants are the primary treatment for DVT as they prevent blood clots from getting bigger and reduce the risk of new clots forming. This helps prevent complications like pulmonary embolism. Elevating the leg and applying compression (option B) can help with symptoms but do not address the underlying cause. Providing anticoagulant therapy (option C) is similar to the correct answer but lacks specificity. Applying compression stockings (option D) can help prevent complications but do not treat the existing clot.