A nurse is caring for a patient receiving anticoagulant therapy. What is the priority nursing intervention?

Correct Answer: C

Rationale: The correct answer is C: Monitor the patient's respiratory rate. This is the priority nursing intervention because anticoagulant therapy can lead to potential bleeding complications, such as pulmonary embolism. Monitoring the patient's respiratory rate helps assess for signs of bleeding or clot formation in the lungs, which are critical to address promptly. A: Monitoring INR levels is important but not the priority over assessing for immediate complications. B: Increasing fluid intake may be beneficial for some conditions but is not the priority in this case. D: Administering an antifungal medication is unrelated to anticoagulant therapy and not a priority intervention.

Correct Answer: B

Rationale: The correct answer is B: Encourage the patient to sit up at the bedside in a chair and lean forward. This position, known as the orthopneic position, helps improve ventilation in COPD patients by reducing the pressure on the diaphragm and allowing for better expansion of the lungs. By sitting up and leaning forward, the patient can maximize their lung capacity and facilitate better gas exchange. A: Having the patient rest in bed with the head elevated to 15 to 20 degrees may help with breathing comfort but does not provide the same level of lung expansion as the orthopneic position. C: Resting in bed in a high-Fowler's position with the knees flexed may help with respiratory effort but does not promote optimal ventilation like sitting up in a chair and leaning forward. D: This is a duplicate of option C. In summary, option B is the best choice as it directly supports improved ventilation and gas exchange in COPD patients compared to the other options.

Correct Answer: B

Rationale: The correct answer is B: Administer a corticosteroid. The priority intervention is to address the potential cause of the severe headache, which could be due to increased intracranial pressure (ICP) resulting from the stroke. Corticosteroids, such as dexamethasone, are often used to reduce brain edema and inflammation in stroke patients. Administering analgesics (choice A) may provide temporary relief but does not address the underlying issue. Assessing respiratory status (choice C) is important but not the priority in this case. Administering beta-agonists (choice D) is not indicated for managing a severe headache in a stroke patient.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. Nitroglycerin is the priority action for chest pain in a patient with a history of hypertension as it helps dilate blood vessels, reducing cardiac workload and improving blood flow to the heart. This can help alleviate chest pain in the setting of a possible myocardial infarction. Aspirin (B) is also commonly given to patients with chest pain to prevent clot formation, but nitroglycerin takes precedence in this scenario. Sublingual nitroglycerin (C) is specifically mentioned as the correct choice, as it is a rapid-acting form of the medication. Corticosteroids (D) are not indicated for the immediate management of chest pain in this context.

Correct Answer: A

Rationale: The correct answer is A: Administer pain medications. Severe pain can lead to increased stress and complications in postoperative patients. Administering pain medications is the priority intervention to provide comfort, improve patient outcomes, and ensure adequate pain management. Antiemetics (B) are used to treat nausea and vomiting, not pain. Administering fluids and electrolytes (C) is important but not the priority in this scenario. Administering a platelet inhibitor (D) is unrelated to managing severe pain in a postoperative patient.