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 because memory loss after a fall can be indicative of a more serious issue like a head injury or neurological problem. A complete mental health examination by the nurse can help assess the extent of memory loss, identify potential causes, and determine appropriate interventions. Referring to a psychometrician (choice B) may not address the immediate health concern. Integrating the mental health examination into history taking and physical examination (choice C) is important but may not be as thorough as a complete mental health examination by a professional. Reassuring the wife that memory loss is normal (choice D) may lead to overlooking a potentially serious health issue.

Correct Answer: D

Rationale: The correct answer is D: Administer corticosteroids. In a client with chest pain and a history of myocardial infarction, the first priority is to address potential inflammation in the myocardium. Corticosteroids help reduce inflammation and stabilize the myocardium, which is crucial in preventing further damage post-myocardial infarction. Administering nitroglycerin (A) is important for vasodilation, but it is typically used after corticosteroids. Morphine (B) and analgesics (C) may provide pain relief but do not address the underlying inflammation. Administering corticosteroids is the most appropriate first step to manage myocardial inflammation and protect the heart tissue.

Correct Answer: A

Rationale: The correct answer is A: Apply a sterile dressing. Firstly, cover the wound with a sterile occlusive dressing to prevent air from entering the pleural space, reducing the risk of tension pneumothorax. This also helps to prevent infection and further complications. Administering morphine (B) or nitroglycerin (D) is not the priority in this situation as managing the chest wound is crucial. Applying an airtight dressing (C) may lead to tension pneumothorax if not done properly. Therefore, the immediate action should be to apply a sterile dressing to stabilize the wound and prevent further complications.

Correct Answer: D

Rationale: The correct answer is D: Atelectasis and pneumonia. Following abdominal surgery, patients are at risk for atelectasis (lung collapse) due to shallow breathing and pneumonia due to impaired lung function. A nurse should monitor for signs such as decreased oxygen saturation, increased respiratory rate, and crackles on auscultation. Wound infection (A) is a common post-operative complication but not specific to abdominal surgery. Hyperglycemia (B) may occur due to stress response but is not directly related to abdominal surgery. Dehydration (C) is a concern post-operatively, but respiratory complications like atelectasis and pneumonia are higher priority due to potential life-threatening consequences.

Correct Answer: D

Rationale: The correct answer is D: sodium chloride. Intestinal suctioning in a client with an ileus leads to loss of fluids rich in sodium chloride. This loss can result in electrolyte imbalances and dehydration. Calcium (A), magnesium (B), and potassium (C) are not typically lost in significant amounts through intestinal suctioning in the context of an ileus. Therefore, sodium chloride is the most likely electrolyte to be lost in this scenario.

Correct Answer: C

Rationale: The correct answer is C: explaining progression of the disease to the client and family. This measure helps the client and family understand the disease, leading to better coping and acceptance, thus promoting a positive body image. Administering immune globulin (A) is not directly related to body image. Assessing extremities (B) and heart sounds (D) are important for monitoring the disease but do not directly impact body image.

Correct Answer: B

Rationale: The correct answer is B: Provide a source of fast-acting carbohydrate. In hypoglycemia, the priority is to raise blood glucose levels quickly to prevent complications like seizures or loss of consciousness. Fast-acting carbs like juice or glucose tablets are the first-line treatment. Administering insulin (choice A) would lower blood sugar further. Administering an oral hypoglycemic agent (choice C) takes time to work and is not suitable for emergencies. Monitoring blood pressure (choice D) is important but not the priority in this situation.

Correct Answer: B

Rationale: The correct answer is B: Perform a comprehensive physical exam. This is important because it helps assess the overall health status of the client, including cardiovascular risk factors that can affect both diabetes and hypertension. Monitoring blood glucose (A) is important for diabetes management but not specific to newly diagnosed hypertension. Checking for protein in the urine (C) is important for assessing kidney function in diabetes, but not the most crucial assessment for newly diagnosed hypertension. Assessing for urinary retention (D) is not directly related to managing diabetes and hypertension.