A 45-year-old man arrives at the clinic and tells the nurse that he has been experiencing severe chest pain. Upon assessment, the nurse notes that his pain radiates to his left arm. The nurse's priority action would be:

Correct Answer: B

Rationale: The correct answer is B: Assess vital signs and oxygen saturation levels. This is the priority action because the patient's symptoms suggest a possible cardiac event. Assessing vital signs and oxygen saturation levels can provide crucial information on the patient's condition and help determine the urgency of the situation. Administering pain medication (choice A) should not be done before assessing the patient's vital signs. Having the patient walk around (choice C) could worsen the situation if it is indeed a cardiac event. Ordering an EKG (choice D) is important but should come after assessing vital signs to guide further evaluation and treatment.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. In hypoglycemia, the priority is to raise the low blood sugar levels quickly. Administering glucose is the most direct and effective way to do so. Glucose will rapidly increase the blood sugar levels and help the client recover from hypoglycemia. Administering insulin (B) would further lower blood sugar levels. Administering glucagon (C) is used for severe hypoglycemia when the client is unconscious. Encouraging deep breathing (D) is not effective in treating hypoglycemia and does not address the immediate need to raise blood sugar levels.

Correct Answer: A

Rationale: The correct answer is A: database. The patient's record, laboratory studies, objective data, and subjective data collectively form the database in healthcare. This term refers to a comprehensive collection of all pertinent information about a patient that is used for analysis, diagnosis, and treatment planning. The other choices are incorrect because B: admitting data specifically refers to information gathered at the time of admission, C: financial statement pertains to financial information, and D: discharge summary summarizes the patient's care and treatment at the time of discharge, not the entire patient record.

Correct Answer: A

Rationale: Rationale for Correct Answer A: 1. Using the defrost setting on microwave ovens to warm bottles is safe because it ensures even heating without creating hot spots that could burn the baby's mouth. 2. This method helps to preserve the nutrients in the breast milk or formula. 3. It is important to warm the bottle to body temperature to mimic the natural feel of breast milk for the baby's comfort. Summary of Incorrect Choices: B: Feeding the baby partially used bottles after 24 hours can increase the risk of bacterial contamination and foodborne illness. C: Mixing two parts water and one part concentrate for formula concentrate is incorrect as it may dilute the formula, leading to inadequate nutrition for the baby. D: Adding new formula to partially used bottles can alter the balance of nutrients and increase the risk of contamination, affecting the baby's health.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. During an acute asthma attack, bronchodilators are the first-line treatment to quickly relieve bronchospasm and improve airflow. They work by relaxing the muscles around the airways, allowing the client to breathe easier. Administering corticosteroids (choices B and C) is important but typically done after bronchodilators to reduce airway inflammation. Encouraging fluid intake (choice D) is not the priority in an acute asthma attack, as the focus should be on addressing the breathing difficulty promptly.

Correct Answer: A

Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial for patients with diabetes and peripheral neuropathy to prevent complications like infections and ulcers. By inspecting their feet daily, the patient can identify any injuries or abnormalities early and seek prompt medical attention. This proactive approach can help prevent serious consequences such as amputations. Summary of incorrect choices: B: Taking medications only when experiencing symptoms - This is not recommended as medications for diabetes and neuropathy are often prescribed to prevent complications and manage the conditions on a daily basis. C: Exercising to increase foot circulation - While exercise is beneficial, patients with peripheral neuropathy may have decreased sensation in their feet, increasing the risk of injury during exercise. D: Wearing tight-fitting shoes to avoid blisters - Tight-fitting shoes can cause pressure points and increase the risk of foot injuries, especially in patients with neuropathy.

Correct Answer: B

Rationale: The correct answer is B: Palpation. Palpation is the most effective technique for assessing the patient's abdominal organ size as it allows the healthcare provider to feel and evaluate the size, texture, and consistency of the abdominal organs through touch. This hands-on approach provides valuable information about any abnormalities or tenderness in the organs. Inspection (choice A) involves looking at the abdomen for any visible signs but does not provide information on organ size. Percussion (choice C) involves tapping on the abdomen to assess the density of underlying structures, not specifically organ size. Auscultation (choice D) involves listening to sounds within the abdomen and does not directly assess organ size. Palpation is the preferred method for accurately assessing abdominal organ size due to its tactile nature.

Correct Answer: A

Rationale: The correct answer is A: Chronic kidney disease (CKD). Patients with diabetes and hypertension are at increased risk for developing CKD due to the damaging effects of high blood sugar and elevated blood pressure on the kidneys. The nurse should monitor for signs and symptoms of kidney dysfunction such as proteinuria, elevated creatinine levels, and decreased glomerular filtration rate. B: Chronic pain is not directly related to the patient's history of diabetes and hypertension. While the patient may experience pain as a result of complications from these conditions, it is not the primary complication to monitor for in this case. C: Hypotension, or low blood pressure, is not a common complication associated with diabetes and hypertension. These conditions typically lead to high blood pressure rather than low blood pressure. D: Sepsis is a serious infection that can occur in any patient, but it is not a direct complication specifically related to diabetes and hypertension. Monitoring for sepsis would be important in a broader context but is not

Correct Answer: D

Rationale: The correct answer is D: discuss how the patient's food choices may affect her health and that of her baby. This is the most appropriate response because it addresses the potential impact of the patient's current diet on her health and the health of her baby during pregnancy. By discussing the implications of her food choices, the nurse can educate the patient on the importance of a balanced and nutritious diet for a healthy pregnancy. This approach promotes awareness and empowers the patient to make informed decisions for her and her baby's well-being. Incorrect choices: A: This option does not provide guidance or education on improving the patient's diet, which is crucial for a healthy pregnancy. B: Focusing on weight gain rather than nutritional content may not address the underlying issue of poor dietary choices. C: Assuming the patient's ability to cook or go grocery shopping may not address the immediate need for dietary education and guidance.