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: C

Rationale: The correct answer is C: Monitor for transfusion reactions. When a client receiving a blood transfusion develops chills, it may indicate a transfusion reaction, such as a febrile non-hemolytic reaction. The nurse's first priority is to monitor the client closely for other signs of a reaction, such as fever, rash, or shortness of breath. Stopping the transfusion may be necessary, but monitoring for reactions is crucial to identify and manage any adverse effects promptly. Vital signs should be monitored as part of assessing for reactions. Performing a lumbar puncture is not indicated in this situation and is unrelated to managing a transfusion reaction.

Correct Answer: B

Rationale: The correct answer is B: Increase potassium intake. Potassium helps to lower blood pressure by counteracting the effects of sodium. This dietary change is crucial for managing hypertension. Increasing sodium intake (choice A) is incorrect as it can lead to increased blood pressure. Increasing fiber intake (choice C) is beneficial for overall health but not specifically for hypertension. Increasing alcohol intake (choice D) is harmful and can worsen hypertension. Prioritizing increasing potassium intake is essential for effectively managing hypertension.

Correct Answer: A

Rationale: The correct answer is A because the amount of alcohol that is safe during pregnancy is unknown. It is recommended to avoid alcohol completely to prevent any potential harm to the developing fetus. B is incorrect because there is no known safe level of alcohol consumption during pregnancy. C is incorrect as any amount of alcohol can potentially harm the fetus. D is incorrect as using alcohol to relax during pregnancy is not recommended due to the associated risks.

Correct Answer: C

Rationale: The correct answer is C. The nurse should prevent infiltration of calcium to avoid tissue necrosis and sloughing. Infiltration of calcium can lead to severe tissue damage due to its caustic nature. Therefore, the nurse should be vigilant in monitoring the IV site and ensuring proper placement to prevent this complication. Choice A is incorrect because infusing hypertonic solutions rapidly can lead to fluid overload and electrolyte imbalances. Choice B is incorrect because exceeding the recommended amount of potassium per liter of fluid can result in hyperkalemia, which can be dangerous. Choice D is incorrect because calcium does not diminish digitalis's action; in fact, calcium can potentiate the effects of digitalis.

Correct Answer: C

Rationale: The correct answer is C, stab wound to the chest. This injury is the highest priority because it poses the greatest risk to the client's life due to potential damage to vital organs and major blood vessels. Immediate intervention is crucial to prevent severe bleeding, pneumothorax, or cardiac tamponade. Treating this injury promptly can significantly increase the client's chances of survival. The other choices are incorrect because: A: An open leg fracture, while serious, does not typically pose an immediate life-threatening risk compared to a stab wound to the chest. B: An open head injury can be severe, but not all head injuries are immediately life-threatening. D: Traumatic amputation of a thumb, while traumatic and painful, is not a priority compared to injuries that directly threaten a client's life.

Correct Answer: B

Rationale: The correct answer is B: "Are you able to dress yourself?" This question is the most important because it directly assesses the patient's functional abilities post-stroke, providing crucial information about their independence and self-care abilities. It helps determine the patient's level of disability and need for assistance with activities of daily living. Choice A: "Do you wear glasses?" is not as important in this context as it does not directly address the patient's functional status post-stroke. Choice C: "Do you have any thyroid problems?" is irrelevant to the functional assessment of a patient post-stroke. Choice D: "How many times a day do you have a bowel movement?" is not as critical as assessing the patient's ability to perform basic activities of daily living.

Correct Answer: D

Rationale: The correct answer is D because polio, pertussis, and measles are highly infectious diseases that can have severe consequences if not prevented through vaccination. Polio can cause paralysis, pertussis can be fatal in infants, and measles can lead to complications like pneumonia and encephalitis. Emphasizing these vaccines can significantly reduce the risk of outbreaks and protect public health. Choice A is incorrect because HPV and genital herpes are sexually transmitted infections, and although important, they are not typically prevented through vaccines like polio, pertussis, and measles. Choice B is incorrect because pneumonia, HIV, and mumps, while serious diseases, do not have vaccines that are as universally recommended for prevention as polio, pertussis, and measles. Choice C is incorrect because syphilis and gonorrhea are sexually transmitted infections, and pneumonia is not typically prevented through vaccination as effectively as polio, pertussis, and measles.

Correct Answer: C

Rationale: The correct answer is C: small intestine. This is because the small intestine is where the majority of nutrient absorption takes place due to its large surface area and presence of villi for absorption. The stomach (A) primarily functions in digestion, not absorption. The pancreas (B) produces digestive enzymes but does not directly absorb nutrients. The gallbladder (D) stores bile produced by the liver to aid in digestion but does not participate in absorption directly.