What should be the first step in managing a client with suspected spinal cord injury?

Correct Answer: A

Rationale: The correct first step is to immobilize the spine (A) in a suspected spinal cord injury to prevent further damage. This helps to stabilize the spine and prevent any potential movement that could worsen the injury. Providing pain relief (B) should come after immobilization. Assessing for signs of spinal shock (C) is important but comes after immobilization. Placing the client in a supine position (D) can be part of immobilization but is not the first step.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. In acute renal failure, maintaining adequate hydration is crucial to support kidney function and prevent further damage. IV fluids help improve renal perfusion and promote urine output. Hemodialysis may be necessary in severe cases but initial intervention is fluid resuscitation. Administering pain relief or morphine is not the priority in acute renal failure as addressing hydration status takes precedence over pain management.

Correct Answer: A

Rationale: The correct first action when a client develops a fever after surgery is to administer antipyretics (A). Fever post-surgery can indicate infection, and antipyretics help lower the body temperature. Administering pain medications (B) may mask the fever's underlying cause. Providing fluids (C) is essential but not the priority. Providing wound care (D) is important but comes after addressing the fever. Administering antipyretics promptly helps manage the fever and allows for further assessment and intervention if needed.

Correct Answer: A

Rationale: The correct answer is A: Administer pain medication. This is the most appropriate nursing intervention because severe pain post-surgery requires immediate relief to ensure the client's comfort and aid in recovery. Pain medication helps manage pain effectively, improving the client's overall well-being and promoting healing. Monitoring vital signs (choice B) is important but secondary to pain relief in this scenario. Administering IV fluids (choice C) may be necessary for hydration but does not directly address the pain. Administering corticosteroids (choice D) is not typically indicated for severe pain post-surgery.

Correct Answer: A

Rationale: The correct answer is A, administer insulin, because hyperglycemia indicates high blood sugar levels which can be effectively lowered by administering insulin. Insulin helps to move glucose from the blood into cells for energy production. Administering fluids (B) can be helpful for dehydration, but it does not directly address the high blood sugar levels. Encouraging activity (C) may help lower blood sugar levels over time, but in the immediate situation, administering insulin is more effective. Encouraging deep breathing (D) does not directly address hyperglycemia and would not be the appropriate first step in managing this condition.