What should the nurse do when a client develops a deep vein thrombosis (DVT)?

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants help prevent the blood clot from getting larger and reduce the risk of it breaking loose and causing a pulmonary embolism. Other choices are incorrect because B: Monitoring vital signs alone does not treat the DVT, C: Providing bed rest can increase the risk of complications like pulmonary embolism, and D: Administering fibrinolytics is not the first-line treatment for DVT.

Correct Answer: B

Rationale: The correct answer is B: Provide oxygen therapy. For a client with shortness of breath and a history of heart failure, oxygen therapy is the most effective intervention as it helps improve oxygenation and relieve respiratory distress. Administering diuretics may help manage fluid retention but does not directly address the breathing difficulty. Encouraging deep breathing may be beneficial for some respiratory conditions but may not be sufficient for a client with heart failure and shortness of breath. Applying oxygen therapy is similar to providing oxygen therapy and can help improve oxygen levels, but providing oxygen therapy is more specific and effective in this case.

Correct Answer: A

Rationale: The correct answer is A: Immobilize the spine. This is the most appropriate intervention for a client with a suspected spinal cord injury to prevent further damage. Immobilization helps stabilize the spine and reduce the risk of spinal cord compression or injury. Administering pain relief (B) or IV fluids (C) should only be done after proper spinal immobilization to avoid exacerbating the injury. Placing the client in a supine position (D) can be beneficial if done carefully after spine immobilization, but immobilizing the spine takes precedence to prevent any potential movement that could worsen the injury.

Correct Answer: A

Rationale: The correct first step is to administer pain relief (Choice A) because addressing the client's pain is a top priority to ensure their comfort and well-being. Pain management is crucial post-surgery to prevent complications and aid in recovery. Monitoring vital signs (Choice B) is important but should follow pain relief to ensure the client's stability. Assessing the wound (Choice C) is necessary but not the immediate priority when the client is in acute pain. Applying a warm compress (Choice D) may provide temporary relief but does not address the underlying cause of the pain. Therefore, administering pain relief is the most appropriate initial action to alleviate the client's discomfort and start the healing process effectively.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. In shock, the priority nursing action is to restore intravascular volume to improve tissue perfusion. IV fluids help increase blood pressure and cardiac output, addressing the underlying cause of shock. Monitoring vital signs (B) is important but administering fluids takes precedence. Administering fluids (C) is a general term and does not specify the urgency of IV fluids. Administering blood transfusion (D) may be indicated in certain types of shock but is not the initial priority.