A nurse is assessing a patient who is experiencing dizziness and weakness. The nurse should prioritize which of the following?

Correct Answer: A

Rationale: The correct answer is A: Blood pressure measurement. Dizziness and weakness can be symptoms of hypotension or low blood pressure. Prioritizing blood pressure measurement is crucial because it can indicate if the patient is at risk of complications like cardiovascular collapse. Pulse oximetry (B) is important for assessing oxygen levels in the blood but may not directly address dizziness and weakness. Blood glucose levels (C) are important but not the priority in this scenario. Cardiac monitoring (D) may be necessary but should come after assessing blood pressure to rule out immediate life-threatening conditions.

Correct Answer: B

Rationale: The correct answer is B: Do not use underarm deodorant. This is important because deodorant can interfere with the mammogram results, leading to false readings. It is crucial to have a clean and uncontaminated image for an accurate diagnosis. Choice A is incorrect as it can affect the quality of the mammogram. Choices C and D are irrelevant to the mammography procedure and not necessary instructions for the client.

Correct Answer: B

Rationale: The correct answer is B because the mental health examination should be integrated into the health history interview. This allows for a comprehensive understanding of the patient's mental health status. Gathering mental health information during the health history interview is crucial as it provides insight into the patient's current mental state, past history, and potential risk factors. This integrated approach is efficient and effective in assessing the patient's mental health needs. A is incorrect because while family input can be valuable, it is not always the best or only resource for information about coping skills. C is incorrect as integrating the mental health examination into the health history interview should not necessarily take an enormous amount of extra time if done efficiently. D is incorrect as a complete mental health examination may not always be necessary to assess the patient's level of functioning; integrating mental health information into the health history interview can often provide sufficient insight.

Correct Answer: A

Rationale: The priority nursing intervention for a client with asthma experiencing wheezing is to administer oxygen. Wheezing indicates airway constriction and decreased oxygenation, making oxygen crucial for adequate tissue perfusion. Administering oxygen helps improve oxygen levels, alleviate respiratory distress, and prevent hypoxemia. Applying a bronchodilator (Choice B) may be beneficial after oxygen is administered. Applying a cold compress (Choice C) is not indicated for asthma exacerbations, and encouraging deep breathing (Choice D) may worsen respiratory distress in a client with wheezing. In summary, administering oxygen is the priority intervention to address the immediate respiratory needs of the client with asthma and wheezing.

Correct Answer: B

Rationale: The correct answer is B: Monitor for signs of infection. Within the first 48 hours post-op, fever is often indicative of an infection. Monitoring for signs such as increased pain, redness, swelling, warmth at the surgical site, elevated white blood cell count, and changes in vital signs helps in early detection and prompt treatment of infections. Administering antipyretics (choice A) may help reduce fever but does not address the underlying cause. Administering fluids (choice C) is important for hydration but does not directly address the fever's cause. Performing an abdominal assessment (choice D) is not specific to addressing fever in a post-op client.

Correct Answer: B

Rationale: The correct answer is B: Encouraging deep breathing and coughing exercises. This is prioritized in the immediate post-operative period to prevent respiratory complications like atelectasis and pneumonia. Deep breathing helps to expand the lungs and coughing helps clear secretions. Administering pain medication (A) is important but not the top priority. Monitoring for signs of infection (C) is crucial but usually done after ensuring respiratory stability. Providing solid food (D) is contraindicated initially to prevent post-operative complications like ileus.

Correct Answer: C

Rationale: The correct answer is C: Shortness of breath and chest pain. This is most concerning because it could indicate a pulmonary embolism, a serious complication of DVT where a blood clot travels to the lungs. Shortness of breath and chest pain are signs of compromised respiratory and cardiac function. A: Pain and swelling in the leg are common symptoms of DVT but not as concerning as symptoms of a pulmonary embolism. B: Redness and warmth around the affected area are typical signs of inflammation associated with DVT but do not indicate a life-threatening complication like a pulmonary embolism. D: Pale skin and decreased pulse in the affected leg could be signs of compromised circulation due to DVT, but they are not as immediately life-threatening as symptoms of a pulmonary embolism.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. In acute renal failure, the priority is to maintain adequate hydration to support kidney function. IV fluids help improve renal perfusion and urine output. Monitoring vital signs is important but not the priority. Performing a kidney function test can provide valuable information but does not address the immediate need for fluid resuscitation. Administering IV antibiotics may be necessary if there is an infection contributing to renal failure, but hydration takes precedence. In summary, administering IV fluids is crucial to support kidney function in acute renal failure, making it the top priority among the choices given.

Correct Answer: B

Rationale: The correct answer is B: Edema and proteinuria. In CKD, the kidneys are unable to filter waste products effectively, leading to fluid retention (edema) and protein leaking into the urine (proteinuria). Edema occurs due to fluid buildup from decreased kidney function. Proteinuria is a result of damaged glomeruli in the kidneys, allowing proteins to leak into the urine. Weight loss and polyphagia (excessive hunger) are not typical symptoms of CKD. Hypertension and tachycardia can occur in CKD due to fluid overload and electrolyte imbalances. Hypothermia and bradycardia are not common symptoms of CKD and would be more indicative of other conditions.