Which intervention should the nurse implement for a client with hypothermia?

Correct Answer: B

Rationale: The correct answer is B, removing the client from the cold environment. This is because hypothermia occurs when the body loses heat faster than it can produce it, and being in a cold environment exacerbates this process. By removing the client from the cold environment, the nurse helps stop further heat loss. Warming the client slowly (A) can be detrimental as rapid rewarming can lead to complications. Providing a warm environment (C) and applying warm blankets (D) are important interventions but should come after removing the client from the cold environment to prevent further heat loss.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. Hypoglycemia is low blood sugar, and administering glucose rapidly raises blood sugar levels to restore normal function. Glucagon (choice B) is used for severe hypoglycemia when the individual cannot consume oral glucose. Insulin (choice C) lowers blood sugar levels and is contraindicated in hypoglycemia. Corticosteroids (choice D) can worsen hypoglycemia by affecting glucose metabolism. Administering glucose is the most direct and effective intervention for hypoglycemia.

Correct Answer: B

Rationale: The correct answer is B: Monitor abdominal pain. This is the priority assessment for a client with acute pancreatitis because it helps determine the severity of the condition and guides the treatment plan. Abdominal pain is a key symptom of pancreatitis and monitoring its intensity, location, and changes over time is crucial. Assessing vital signs (choice A) is important but secondary to monitoring pain. Monitoring serum amylase levels (choice C) is relevant for diagnosis but not immediate priority. Performing a CT scan (choice D) may be necessary later for further evaluation but is not the initial priority in managing acute pancreatitis.

Correct Answer: A

Rationale: The correct answer is A: Administer diuretics. Diuretics help reduce fluid overload in CHF by increasing urine output and decreasing the workload on the heart. This intervention addresses the underlying issue of fluid retention, a common problem in CHF. Monitoring vital signs (B) is important but does not directly target the primary problem of fluid overload. Monitoring respiratory rate (C) is essential in CHF, but administering diuretics takes precedence in managing fluid balance. Monitoring for arrhythmias (D) is important, but not the most crucial intervention in the management of CHF.

Correct Answer: A

Rationale: The correct answer is A: Provide tracheostomy care. This is the priority because maintaining the patency of the airway is crucial in a client with a tracheostomy. Tracheostomy care includes monitoring for any signs of respiratory distress, ensuring the tube is secure, assessing for any obstructions, and providing appropriate humidification. Suctioning the airway (choice B) and suctioning the tracheostomy (choice D) are important interventions but come after ensuring proper tracheostomy care. Changing the dressing (choice C) is also important but not as immediate as ensuring the airway remains clear and functional.