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 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: B

Rationale: The correct answer is B: Provide IV fluids. The first step in caring for a client with severe burn injuries is to ensure adequate hydration and prevent hypovolemic shock. IV fluids are crucial to replace lost fluids and maintain circulation. Cooling the burn site (choice A) may be important but not the first step. Providing pain relief (choice C) is important but not as critical initially. Initiating IV fluids (choice D) is similar to the correct answer, but providing IV fluids is more urgent than initiating them.

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: D

Rationale: The correct answer is D: Morton's neuroma. This condition typically presents as a mass in the foot causing pain and difficulty walking. The nurse should document it as Morton's neuroma because it specifically refers to a benign growth of nerve tissue between the toes. Plantar fasciitis (A) is inflammation of the tissue on the bottom of the foot, not a mass. Hallux valgus (B) is a bunion deformity of the big toe joint. Hammertoe (C) is a deformity of the toe joints. Therefore, the correct choice is D as it aligns with the description of a mass causing difficulty walking.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. The first priority in caring for a client experiencing a stroke is to ensure adequate oxygen supply to the brain, as lack of oxygen can lead to further brain damage. Administering oxygen helps improve oxygenation and can prevent complications. Administering morphine (B) is not recommended as it can mask symptoms and delay diagnosis. Administering IV fluids (C) may be necessary but is not the first priority. Administering fibrinolytics (D) is a time-sensitive intervention for ischemic stroke but should be done after proper evaluation and confirmation of the type of stroke.

Correct Answer: B

Rationale: The correct answer is B because an ethnic group is defined by shared heritage, culture, language, and/or religion. This definition encompasses a wider range of factors that contribute to the identity of a group of people. Choice A is too limited as history alone does not define an ethnic group. Choice C is incorrect because ethnicity is not solely based on race or national origins. Choice D is also incorrect because relatedness and religious affiliations alone do not encompass the full scope of what defines an ethnic group.

Correct Answer: B

Rationale: The main role of the nursing process in community health care is to provide individualized care frameworks. This involves assessing, diagnosing, planning, implementing, and evaluating care tailored to each patient's unique needs. Nursing interventions are personalized based on the individual's health status, preferences, and community resources. This approach promotes holistic and patient-centered care, leading to better health outcomes. The other choices are incorrect because: A: Implementing standardized treatment plans does not account for individual variations and needs. C: Nurses collaborate with diagnostic physicians but do not solely assist them. D: Establishing clinical guidelines is important but not the primary role of the nursing process in community health care.

Correct Answer: A

Rationale: The correct answer is A: Apply a splint. This is the first step because immobilizing the affected limb helps prevent further injury and reduces pain. Administering fluids (B) and oxygen (C) are important but not the priority in this situation. Elevating the limb (D) can wait until the fracture is stabilized.