Which action should the nurse take when a client exhibits signs of infection at a surgical site?

Correct Answer: B

Rationale: The correct answer is B because cleansing and dressing the wound is crucial in preventing further infection spread. First, cleansing the wound removes debris and pathogens, reducing the risk of infection. Second, dressing the wound protects it from external contaminants. This proactive approach promotes wound healing and prevents complications. A: Notifying the healthcare provider is important, but immediate wound care should be prioritized. C: Applying a dressing without cleansing the wound first may trap bacteria and worsen the infection. D: Pain medications are important for client comfort, but addressing the infection source is necessary for proper healing.

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: A

Rationale: The correct answer is A: Place the client in a safe environment. This is the primary intervention for a client with a history of falls to prevent further injury. By ensuring the environment is safe, the risk of falls and subsequent injuries is minimized. Choice B, assessing the client's functional status, is important but not the primary intervention. Choice C, encouraging the client to rest, may not address the underlying issue of fall risk. Choice D, encouraging the client to ambulate, may increase the risk of falls for someone with a history of falls. It is crucial to prioritize safety by modifying the environment to prevent falls.

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.