Which of the ff must the nurse consider when administering IV fluids to clients with hypertension?

Correct Answer: B

Rationale: When administering IV fluids to clients with hypertension, the nurse must closely monitor the site and progress of the infusion every hour to ensure proper hydration and detect any signs of complications such as infiltration or infection. Checking the blood pressure every hour, as in choice A, may not be necessary unless specifically indicated by the healthcare provider. Checking the progress of the infusion once a day, as in choice C, does not provide adequate monitoring for a client with hypertension who may be at higher risk for fluid volume overload. Checking the client's pulse rate every hour, as in choice D, is important but does not directly address the immediate monitoring needs related to the administration of IV fluids.

Correct Answer: C

Rationale: Nerves from the thoracic cord supply the trunk of the body. The thoracic spinal cord region is responsible for supplying nerves to the chest, abdomen, and back—the areas that make up the trunk of the body. Each level of the thoracic spinal cord is associated with specific nerves that innervate different areas of the trunk, including the intercostal muscles, abdominal muscles, and other structures. Therefore, the trunk is the part of the body supplied by nerves from the thoracic cord.

Correct Answer: C

Rationale: ACTH (Adrenocorticotropic hormone) might be ordered to help control symptoms of multiple sclerosis and possibly induce a remission. ACTH is sometimes used as a treatment option for multiple sclerosis due to its anti-inflammatory properties. It can help reduce inflammation in the central nervous system and, in some cases, lead to a decrease in symptoms and possibly induce a remission. However, it is important to note that ACTH is not commonly used as a first-line treatment for multiple sclerosis and is usually reserved for cases that are refractory to other medications.

Correct Answer: A

Rationale: In the presence of coma or unconsciousness, maintaining a clear airway is the major therapeutic measure to ensure adequate breathing and oxygenation. A clear airway is vital for the patient's survival and should be the priority to prevent respiratory distress or failure. Providing good nursing care is important for overall patient well-being, but ensuring a clear airway is crucial for immediate life support. Retention of a catheter is not a major therapeutic measure in the context of coma or unconsciousness unless specifically indicated for monitoring or treatment of underlying conditions. Therefore, the most critical intervention in this scenario is the maintenance of a clear airway.

Correct Answer: A

Rationale: The Snellen chart is a chart used to measure visual acuity. The numbers in a Snellen fraction indicate the distance from which a person with normal eyesight can see the letters on the chart. In the case of 20/80, this means that the person can see at 80 feet what a person with normal eyesight can see at 20 feet. So, option A is correct as it accurately explains what is indicated by a Snellen chart finding of 20/80.