What should be the primary action for a client who has just vomited 300 cc of bright red blood?

Correct Answer: D

Rationale: The correct first action for a client who has just vomited 300 cc of bright red blood is to check the blood pressure. This assessment is crucial to evaluate for hypotension, which could indicate significant blood loss and the need for immediate intervention. Documenting the vomiting is important for the client's medical record but not the initial priority. Increasing IV fluids and getting a complete blood count are necessary steps but should follow the assessment of the client's hemodynamic status.

Correct Answer: C

Rationale: The correct answer is 6 liters/minute. When a client needs oxygen therapy, the highest flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Higher flow rates must be delivered by a mask. Choices A, B, and D are incorrect because they suggest flow rates that exceed what can be effectively delivered through a nasal cannula.

Correct Answer: C

Rationale: To provide total oral care to a client, the nurse should first assemble all necessary equipment. Placing the client in a side-lying position helps fluids to easily flow out or pool in the side of the mouth for suctioning, thus preventing aspiration. Additionally, placing a towel under the client's chin and a curved basin against the chin helps to maintain cleanliness during the procedure. Choice A is incorrect because the client should be placed in a side-lying position, not a semi-Fowler's position which is used for respiratory issues. Choice B is incorrect as it does not emphasize the importance of proper positioning for effective oral care. Choice D is incorrect as it oversimplifies the procedure by focusing only on cleaning the mouth without considering the importance of positioning and preparation.

Correct Answer: B

Rationale: The correct answer is B. Restraints are used as an emergency intervention when all other options to protect a client from imminent danger have been exhausted. Restraints should only be used as a last resort to ensure the safety of the client and others. Choices A, C, and D are incorrect because restraints are not used to maintain control, reinforce behavior, or are exclusively taken under direct physician supervision. It is crucial to remember that restraint use should always be based on careful assessment, documentation, and adherence to legal and ethical guidelines.

Correct Answer: D

Rationale: When a client with an ileus is placed on intestinal tube suction, the primary electrolyte lost is sodium chloride. Duodenal intestinal fluid contains potassium (K+), sodium (Na+), and bicarbonate. Suctioning is done to remove excess fluids, leading to a decrease in the client's sodium chloride levels. Therefore, options A, B, and C are incorrect as calcium, magnesium, and potassium are not the primary electrolytes lost during intestinal suction in a client with an ileus.