What should the nurse do first for a client with a history of diabetes who is experiencing hypoglycemia?

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. In hypoglycemia, the priority is to raise the low blood sugar levels quickly. Administering glucose is the most direct and effective way to do so. Glucose will rapidly increase the blood sugar levels and help the client recover from hypoglycemia. Administering insulin (B) would further lower blood sugar levels. Administering glucagon (C) is used for severe hypoglycemia when the client is unconscious. Encouraging deep breathing (D) is not effective in treating hypoglycemia and does not address the immediate need to raise blood sugar levels.

Correct Answer: B

Rationale: The correct answer is B: ondansetron (Zofran). Ondansetron is a selective serotonin receptor antagonist that effectively targets the serotonin receptors in the chemoreceptor trigger zone to relieve nausea and vomiting. It is commonly used in chemotherapy-induced nausea and vomiting. A: Metoclopramide is a dopamine receptor antagonist and primarily used for gastrointestinal motility disorders, not specifically for nausea relief. C: Hydroxyzine is an antihistamine with sedative properties, primarily used for anxiety and itching, not specifically for nausea relief. D: Prochlorperazine is a dopamine receptor antagonist primarily used for treating psychotic disorders, not specifically for nausea relief. In summary, ondansetron is the correct choice as it targets serotonin receptors specifically for relieving nausea and vomiting, whereas the other options focus on different mechanisms of action.

Correct Answer: A

Rationale: The correct answer is A: otosclerosis. Otosclerosis is a condition where abnormal bone growth in the middle ear causes hearing loss. In this case, the patient's symptoms of progressive hearing loss improving with louder sounds suggest conductive hearing loss, which is commonly seen in otosclerosis. Other choices are incorrect because presbycusis is age-related hearing loss, trauma to the bones would typically result in sudden hearing loss, and frequent ear infections are more likely to cause temporary hearing loss rather than progressive loss.

Correct Answer: D

Rationale: The correct answer is D: Administer corticosteroids. In a client with chest pain and a history of myocardial infarction, the first priority is to address potential inflammation in the myocardium. Corticosteroids help reduce inflammation and stabilize the myocardium, which is crucial in preventing further damage post-myocardial infarction. Administering nitroglycerin (A) is important for vasodilation, but it is typically used after corticosteroids. Morphine (B) and analgesics (C) may provide pain relief but do not address the underlying inflammation. Administering corticosteroids is the most appropriate first step to manage myocardial inflammation and protect the heart tissue.

Correct Answer: D

Rationale: The correct answer is D: Atelectasis and pneumonia. Following abdominal surgery, patients are at risk for atelectasis (lung collapse) due to shallow breathing and pneumonia due to impaired lung function. A nurse should monitor for signs such as decreased oxygen saturation, increased respiratory rate, and crackles on auscultation. Wound infection (A) is a common post-operative complication but not specific to abdominal surgery. Hyperglycemia (B) may occur due to stress response but is not directly related to abdominal surgery. Dehydration (C) is a concern post-operatively, but respiratory complications like atelectasis and pneumonia are higher priority due to potential life-threatening consequences.

Correct Answer: A

Rationale: Correct Answer: A (Iron, folic acid, and B12) Rationale: 1. Iron: Renal failure patients often have anemia due to decreased erythropoietin production. 2. Folic acid and B12: Important for red blood cell production and maturation. 3. Corrects underlying causes of anemia in renal failure patients. Summary: B: Increasing protein doesn't directly address anemia in renal failure. C: Vitamin D and calcium are not primary treatments for anemia in renal failure. D: Calcium and folic acid alone do not address the specific deficiencies seen in renal failure anemia.

Correct Answer: A

Rationale: The correct answer is A: Encouraging early ambulation. This is the priority intervention as it helps prevent complications such as blood clots and pneumonia, promotes circulation, and aids in faster recovery. Ambulation also helps maintain joint mobility and muscle strength. Administering pain medications (B) is important but not the priority. Providing wound care (C) and monitoring for infection (D) are important, but ambulation takes precedence in preventing complications.

Correct Answer: C

Rationale: The correct answer is C: explaining progression of the disease to the client and family. This measure helps the client and family understand the disease, leading to better coping and acceptance, thus promoting a positive body image. Administering immune globulin (A) is not directly related to body image. Assessing extremities (B) and heart sounds (D) are important for monitoring the disease but do not directly impact body image.

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.