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: C

Rationale: The correct answer is C: Chocolate. Chocolate is known to trigger heartburn in individuals with GERD due to its high fat content and caffeine. Fat relaxes the lower esophageal sphincter, allowing stomach acid to flow back up the esophagus, leading to heartburn. Caffeine can also relax the sphincter and trigger acid reflux. Lettuce (A) and eggs (B) are generally well-tolerated and do not commonly trigger heartburn. Butterscotch (D) may be high in fat and sugar, but it is less likely to cause heartburn compared to chocolate.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. In sepsis, early fluid resuscitation is crucial to prevent hypotension and organ dysfunction. IV fluids help restore perfusion and stabilize the client. Administering antibiotics (choice B) is important but comes after fluid resuscitation. Performing a blood culture (choice C) is essential but not the first priority. Performing an abdominal assessment (choice D) is not directly related to managing sepsis and should not be the initial priority.

Correct Answer: C

Rationale: Step-by-step rationale: 1. Anisocoria is a condition where pupils are of unequal size. 2. It is typically caused by issues in the eye muscles or nerves controlling pupil size. 3. The nurse would expect to observe pupils of different sizes. 4. Dilated pupils (choice A) and excessive tearing (choice B) are not indicative of anisocoria. 5. An uneven curvature of the lens (choice D) does not directly relate to pupil size differences. Summary: Correct answer C is supported by the definition of anisocoria and its usual presentation. Choices A, B, and D are incorrect as they do not align with the characteristic feature of anisocoria.

Correct Answer: D

Rationale: The correct answer is D because spirituality involves seeking meaning in one's life, which can provide a sense of purpose and fulfillment. This search is personal and introspective, focusing on individual values and beliefs. A, B, and C are incorrect because spirituality is not solely about belief in a supreme being, adherence to a specific system of beliefs, or the pursuit of life after death. Rather, it is about finding meaning, connection, and inner peace in one's existence.

Correct Answer: A

Rationale: The correct answer is A: Epinephrine. It is the first-line treatment for anaphylaxis as it rapidly reverses severe allergic reactions by constricting blood vessels, relaxing airway muscles, and increasing heart rate. Diphenhydramine (B) and steroids (C) are used as adjunct therapies but do not provide immediate relief like epinephrine. Albuterol (D) is used for bronchospasm in asthma, not for anaphylaxis. In summary, epinephrine is the most effective and life-saving medication for treating anaphylaxis.

Correct Answer: D

Rationale: The correct answer is D: It helps equalize air pressure on both sides of the tympanic membrane. The eustachian tube connects the middle ear to the nasopharynx, allowing for pressure equalization. During activities like swallowing or yawning, the tube opens to allow air to flow in or out, maintaining equal pressure. This function is crucial for proper hearing and preventing discomfort or damage to the tympanic membrane. Choice A is incorrect as cerumen is produced by ceruminous glands in the ear canal, not the eustachian tube. Choice B is incorrect as the eustachian tube normally remains closed and opens only intermittently during specific actions. Choice C is incorrect as the eustachian tube does not connect the middle and outer ear; it connects the middle ear to the nasopharynx.

Correct Answer: B

Rationale: The correct answer is B: gout. Uric acid levels are typically checked for gout, a type of arthritis caused by the buildup of uric acid crystals in the joints. This condition directly relates to uric acid levels in the blood. Asthma (choice A), diverticulitis (choice C), and meningitis (choice D) do not typically require checking uric acid levels. Asthma is a respiratory condition, diverticulitis is a gastrointestinal condition, and meningitis is an inflammation of the protective membranes covering the brain and spinal cord.

Correct Answer: B

Rationale: The correct answer is B: Chronic obstructive pulmonary disease (COPD). The patient's history of smoking, persistent cough, and worsening symptoms over months are indicative of COPD, a progressive lung disease commonly caused by smoking. Asthma (A) typically presents with intermittent symptoms, bronchitis (C) may cause cough but not necessarily worsening over time, and pulmonary embolism (D) is characterized by sudden onset symptoms and is less likely in this case. COPD is the most concerning due to the patient's smoking history and progressive symptoms.