What should the nurse do first when a client presents with symptoms of sepsis?

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. The initial priority in managing sepsis is to restore perfusion and oxygenation by giving IV fluids to support blood pressure and organ perfusion. This helps to improve tissue oxygenation and prevents further organ damage. Administering insulin (choice B) is not the priority in the initial management of sepsis. Monitoring blood pressure (choice C) is important but not the first step in the management of sepsis. Administering insulin is also listed twice and is not relevant to the immediate management of sepsis.

Correct Answer: A

Rationale: Administering aspirin is the most appropriate intervention for a client experiencing a heart attack. Aspirin helps prevent blood clot formation, which is crucial in reducing further damage to the heart during a heart attack. It inhibits platelets from clumping together, improving blood flow to the heart muscle. Thrombolytics are used to dissolve existing blood clots, but aspirin is more preventive. Monitoring for arrhythmias is important but not the initial intervention. Administering morphine can be considered for pain relief but is not as crucial as administering aspirin to prevent further clot formation.

Correct Answer: A

Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps open airways, making it effective in treating respiratory distress. It works quickly to relieve symptoms such as shortness of breath and wheezing. Corticosteroids (B) may be used in conjunction with albuterol for severe cases, but albuterol is the immediate intervention. Providing pain relief (C) is not the primary intervention for respiratory distress. Nebulizers (D) are a delivery method for medications like albuterol, but the key intervention is administering the medication itself.

Correct Answer: B

Rationale: The correct answer is B: Place in a safe environment. This is the priority action because it ensures the client's safety by preventing injury during the seizure. Placing the client in a safe environment involves removing any objects that could harm them, such as sharp objects or furniture. Positioning on their side (choice A) is important after the seizure to prevent aspiration. Applying warm compresses (choice C) is not indicated during a seizure. Inserting an oral airway (choice D) is not recommended as it can be dangerous during a seizure and should only be done if the client is not breathing after the seizure.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. The first action should be to ensure the client's oxygenation as chest pain could indicate decreased oxygen supply. Administering oxygen helps improve oxygen levels and can be crucial in managing potential complications. Summary of other choices: B: Administering morphine may mask the pain but doesn't address the underlying issue. C: Administering anticoagulants is not appropriate as the cause of chest pain is not related to clotting. D: Applying a warm compress is not indicated and may delay proper assessment and intervention for the chest pain.