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

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Question 1 of 9

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.

Question 2 of 9

What is the priority nursing intervention for a client with shortness of breath and wheezing?

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.

Question 3 of 9

The Indian Act of 1876 classifies First Nations people into registered status Indians or nonstatus Indians. Knowing a First Nations person's status is important for health care providers, as it:

Correct Answer: C

Rationale: The correct answer is C because knowing a First Nations person's status guides health care providers in planning care. First Nations individuals with status are entitled to specific benefits not covered under provincial health plans. This knowledge helps tailor treatment plans and access appropriate resources. Choice A is incorrect because status does not directly relate to provincial health insurance coverage. Choice B is incorrect as it inaccurately states that only those with status can have unlimited benefits across Canada. Choice D is incorrect because status does not necessarily influence how a person interacts with their community.

Question 4 of 9

Which foods help improve body defenses and potentially prevent diseases?

Correct Answer: A

Rationale: The correct answer is A because broccoli, oranges, and dark greens are rich in essential nutrients like vitamin C, antioxidants, and phytochemicals that boost the immune system and help prevent diseases. Broccoli contains sulforaphane, which has been shown to have anti-cancer properties. Oranges are high in vitamin C, crucial for immune function. Dark greens like spinach and kale are packed with vitamins and minerals that support overall health. Choice B is incorrect because no single food can cure many diseases. Choice C is incorrect because relying solely on vitamin pills may not provide all the necessary nutrients and benefits of whole foods. Choice D is incorrect as there is no scientific evidence supporting the concept of balancing body molecules through food.

Question 5 of 9

The nurse is preparing to examine an infant. Which of the following actions is the most appropriate to perform first?

Correct Answer: C

Rationale: The correct answer is C: Begin with the head. This is the most appropriate action as starting with the head allows the nurse to establish rapport with the infant and assess their level of alertness before progressing further. By starting at the head, the nurse can also observe the infant's facial expressions and interactions with the caregiver, providing valuable information about the infant's overall well-being. Assessing reflexes first (Choice A) may startle the infant, asking the parent to undress the child (Choice B) can be done after the initial assessment, and beginning with the legs (Choice D) does not prioritize the critical areas of observation such as the head and face.

Question 6 of 9

The nurse is interviewing a patient who has a hearing impairment. What technique would be most beneficial in communicating with this patient?

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Assessing the communication method preferred by the patient is crucial as it allows the nurse to tailor the communication approach to the patient's needs. 2. By understanding the patient's preferred communication method, the nurse can ensure effective and respectful communication. 3. This approach promotes patient-centered care and fosters a positive therapeutic relationship. 4. Avoiding facial expressions and hand gestures (B) can hinder communication and may not align with the patient's preferences. 5. Requesting a sign language interpreter (C) may be necessary for some patients, but assessing the patient's preferred method should be the initial step. 6. Speaking loudly and with exaggerated facial movement (D) can be ineffective and may not be the patient's preferred method of communication.

Question 7 of 9

What is the priority nursing action for a client with a severe allergic reaction?

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions as it helps to reverse the symptoms quickly and prevent further complications. Administering corticosteroids (B) may be considered later for long-term management, but epinephrine is the immediate priority. Administering oxygen (C) may help with respiratory distress but does not address the underlying allergic reaction. Applying a cold compress (D) may provide temporary relief for local reactions but is not effective for a severe systemic allergic reaction.

Question 8 of 9

What is the priority nursing action for a client experiencing anaphylaxis?

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis as it quickly reverses severe allergic reactions. It works by constricting blood vessels, relaxing airway muscles, and increasing heart rate. These actions help to counteract the potentially life-threatening symptoms of anaphylaxis, such as difficulty breathing and a drop in blood pressure. Applying antihistamines (B) may help with mild allergic reactions but are not sufficient for anaphylaxis. Administering morphine (C) or pain relief (D) is not appropriate initially as they do not address the immediate life-threatening nature of anaphylaxis.

Question 9 of 9

Which of the following interventions is most appropriate for a client with a deep wound infection?

Correct Answer: B

Rationale: Step 1: Administering IV antibiotics is important for treating infections, but in this case, the focus is on addressing the pain associated with the deep wound infection. Step 2: Administering pain relief helps improve the client's comfort and quality of life while the infection is being treated. Step 3: Changing the dressing is essential for wound care but does not directly address the client's pain from the infection. Step 4: Performing a CT scan may be necessary to assess the extent of the infection, but it does not directly provide immediate relief for the client's pain. Summary: Administering pain relief is the most appropriate intervention as it directly addresses the client's symptoms and improves their comfort level during the treatment of the deep wound infection.

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