Which of the following is the most important intervention for a client with hypovolemic shock?

Correct Answer: A

Rationale: The correct answer is A: Administer fluids. In hypovolemic shock, the primary issue is a lack of circulating blood volume. Administering fluids helps to restore blood volume and improve perfusion to vital organs, addressing the underlying cause of shock. Vasopressors (B) are used in distributive shock, sodium bicarbonate (C) is used for metabolic acidosis, and corticosteroids (D) are typically not indicated in hypovolemic shock. Administering fluids is the most important intervention to stabilize the client's condition in hypovolemic shock.

Correct Answer: C

Rationale: The correct intervention for hyperkalemia is to administer insulin (Choice C). Insulin drives potassium into cells, lowering serum potassium levels. This is effective in acutely reducing high potassium levels. Administering calcium gluconate (Choice A) is used for stabilizing cardiac membranes in hyperkalemia but does not lower potassium levels. Sodium bicarbonate (Choice B) is used for metabolic acidosis, not hyperkalemia. Furosemide (Choice D) is a loop diuretic that can lead to potassium loss but is not the primary intervention for hyperkalemia.

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.