What should the nurse do first when a client with a respiratory infection shows signs of sepsis?

Correct Answer: B

Rationale: The nurse should first administer IV fluids when a client with a respiratory infection shows signs of sepsis. This is because sepsis can lead to severe dehydration and hypotension, and prompt fluid resuscitation is essential to stabilize the client's hemodynamic status. Administering antibiotics (choice A) is important but addressing fluid resuscitation takes precedence. Administering pain medication (choice C) may provide comfort but does not address the underlying issue of sepsis. Providing mechanical ventilation (choice D) may be necessary in severe cases but should be considered after addressing fluid resuscitation.

Correct Answer: D

Rationale: The correct answer is D: Encourage deep breathing exercises. For a client with a history of asthma and wheezing, deep breathing exercises help improve lung function and reduce the frequency of asthma attacks. These exercises can strengthen respiratory muscles, increase lung capacity, and enhance overall breathing efficiency. Administering bronchodilators (choice A) may provide immediate relief but does not address long-term management. Administering oxygen and encouraging fluid intake (choice B) may be helpful in certain situations but does not specifically target asthma symptoms. Administering corticosteroids (choice C) is typically used for severe asthma exacerbations and should not be the first-line treatment for someone with a history of asthma and wheezing.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In respiratory distress, the priority is to ensure adequate oxygenation. Oxygen therapy helps improve oxygen levels in the blood and relieve respiratory distress. Administering diuretics (B) may not address the immediate need for oxygen. Increasing respiratory rate (C) may lead to worsening distress if the underlying cause is not addressed. Administering IV fluids (D) is not the priority unless specifically indicated for the client's condition. It is crucial to prioritize oxygen delivery to support vital functions and stabilize the client's condition.

Correct Answer: B

Rationale: The correct answer is B: Provide IV fluids. The first step in caring for a client with severe burn injuries is to ensure adequate hydration and prevent hypovolemic shock. IV fluids are crucial to replace lost fluids and maintain circulation. Cooling the burn site (choice A) may be important but not the first step. Providing pain relief (choice C) is important but not as critical initially. Initiating IV fluids (choice D) is similar to the correct answer, but providing IV fluids is more urgent than initiating them.

Correct Answer: A

Rationale: The correct answer is A: Use a numeric pain scale. This method allows for quantitative assessment of pain intensity, aiding in accurate pain management. It is widely used in healthcare settings, providing a standardized way to communicate and monitor pain levels. Visual analog scale (B) is subjective and less precise than numeric scales. Facial expression scale (C) may be influenced by cultural factors and is subjective. Observing for signs of depression (D) is important but not specific to assessing pain intensity.