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: B

Rationale: The correct answer is B: Eggs. Eggs are considered a complete protein because they contain all nine essential amino acids required by the body. These amino acids are necessary for various bodily functions, such as muscle growth and repair. Corn (A), peanuts (C), and sunflower seeds (D) are incomplete proteins as they lack one or more essential amino acids. Therefore, eggs are the best choice for a complete protein source compared to the other options provided.

Correct Answer: B

Rationale: The correct answer is B: Increase potassium intake. Potassium helps to lower blood pressure by counteracting the effects of sodium. This dietary change is crucial for managing hypertension. Increasing sodium intake (choice A) is incorrect as it can lead to increased blood pressure. Increasing fiber intake (choice C) is beneficial for overall health but not specifically for hypertension. Increasing alcohol intake (choice D) is harmful and can worsen hypertension. Prioritizing increasing potassium intake is essential for effectively managing hypertension.

Correct Answer: A

Rationale: The correct answer is A: Nursing process. The nursing process consists of systematic steps (assessment, diagnosis, planning, implementation, evaluation) used by nurses to provide individualized care. Assessment helps identify community needs, diagnosis guides problem identification, planning involves setting goals, implementation is about carrying out interventions, and evaluation assesses outcomes. Diagnostic reasoning (B) refers to the process of analyzing data to make clinical decisions, not for planning community care. Critical thinking (C) is a general cognitive process that aids decision-making but is not specific to planning community care. Community care map (D) may be a tool used within the nursing process but is not the overarching framework for planning individualized care.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help dilate the airways, relieving bronchospasm and improving airflow in clients experiencing shortness of breath and wheezing. This intervention directly addresses the underlying cause of the symptoms. Administering corticosteroids (B) may be considered in severe cases to reduce inflammation but is not the priority initial intervention. Administering pain relief (C) is not indicated unless pain is identified as a contributing factor. Placing the client in a sitting position (D) can help improve breathing but does not directly address the bronchoconstriction causing the wheezing.

Correct Answer: D

Rationale: The correct answer is D. The nursing process consists of Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation. Assessment involves gathering data about the patient's health status. Diagnosis is the identification of the patient's health problems. Outcome Identification sets goals for resolving these problems. Planning involves developing a care plan. Implementation is the execution of the care plan. Evaluation assesses the effectiveness of the care provided. Choices A, B, and C are incorrect: A: Treatment and client outcome are not individual phases in the nursing process. B: Admission and discharge planning are not standalone phases in the nursing process. C: Expected outcome is not a phase, and assessment is missing from the sequence.

Correct Answer: A

Rationale: The correct answer is A: Administering diuretics to manage fluid retention. In heart failure, fluid overload can worsen symptoms and lead to complications. Diuretics help reduce excess fluid in the body, relieving strain on the heart. This intervention helps improve cardiac function and alleviate symptoms. Choice B (Encouraging increased physical activity) may be beneficial in some cases, but in heart failure, excessive physical activity can strain the heart further. Choice C (Providing a low-sodium diet) is important in managing heart failure, but diuretics would be more critical initially to address immediate fluid retention. Choice D (Encouraging high-potassium foods) is important for overall health but not the priority in managing heart failure.

Correct Answer: B

Rationale: The correct answer is B because critical thinking helps nurses analyze complex situations, identify relevant information, and plan effective interventions. It allows for systematic problem-solving and decision-making, leading to optimal patient care outcomes. Choice A is incorrect as critical thinking doesn't guarantee immediate answers. Choice C is incorrect because critical thinking complements clinical guidelines rather than replacing them. Choice D is incorrect as physical assessments are essential in nursing care and critical thinking enhances, not bypasses, this process.

Correct Answer: D

Rationale: The correct answer is D because polio, pertussis, and measles are highly infectious diseases that can have severe consequences if not prevented through vaccination. Polio can cause paralysis, pertussis can be fatal in infants, and measles can lead to complications like pneumonia and encephalitis. Emphasizing these vaccines can significantly reduce the risk of outbreaks and protect public health. Choice A is incorrect because HPV and genital herpes are sexually transmitted infections, and although important, they are not typically prevented through vaccines like polio, pertussis, and measles. Choice B is incorrect because pneumonia, HIV, and mumps, while serious diseases, do not have vaccines that are as universally recommended for prevention as polio, pertussis, and measles. Choice C is incorrect because syphilis and gonorrhea are sexually transmitted infections, and pneumonia is not typically prevented through vaccination as effectively as polio, pertussis, and measles.