A nurse is caring for a patient who has a history of hypertension and is experiencing chest pain. What is the priority action?

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. The priority action in this scenario is to address the chest pain, which could be indicative of a myocardial infarction or heart attack. Nitroglycerin helps to dilate blood vessels, improve blood flow to the heart, and relieve chest pain. Administering nitroglycerin promptly can help alleviate the patient's symptoms and potentially prevent further cardiac damage. Choice B (Administer aspirin) is also a common intervention for chest pain, but nitroglycerin is the priority as it directly addresses the underlying cause of chest pain in this case. Choice C (Monitor vital signs) and choice D (Administer IV fluids) are important interventions but are not the priority when a patient with a history of hypertension presents with chest pain, as addressing the potential cardiac issue should be the primary focus.

Correct Answer: B

Rationale: The correct answer is B) Kussmaul respirations. In this scenario, the patient's ABG results show a low pH and low HCO₃⁻ levels, indicating metabolic acidosis. Kussmaul respirations are a compensatory mechanism the body uses to try to lower the acidity in the blood by blowing off excess CO₂ through rapid and deep breathing. This is commonly seen in conditions like diabetic ketoacidosis, where the body is trying to correct the acid-base imbalance. Option A) Intercostal retractions are not typically associated with the ABG results provided in the question. Intercostal retractions are usually seen in conditions where there is increased work of breathing, such as respiratory distress or obstruction. Option C) Low oxygen saturation (SpO₂) is not specifically indicated by the ABG results provided. While the PaO₂ is 85 mm Hg, which is slightly on the lower side, it does not directly correlate with low oxygen saturation. Option D) Decreased venous O₂ pressure is not a typical finding related to the ABG results provided. Venous O₂ pressure is not directly assessed through arterial blood gas measurements and is not relevant in this context. Educationally, understanding how to interpret ABG results is crucial for nurses to provide safe and effective care to their patients. Recognizing the significance of findings like pH, PaCO₂, PaO₂, and HCO₃⁻ can help nurses identify potential underlying conditions and provide appropriate interventions to manage these conditions effectively.

Correct Answer: C

Rationale: The correct answer is C) Put on sterile gloves and use a sterile catheter to suction. When coarse crackles are heard on auscultation of a patient with a tracheostomy tube, it indicates the presence of secretions that need to be cleared to maintain airway patency. Sterile suctioning is the appropriate intervention to effectively remove these secretions and prevent respiratory compromise. Option A) Encouraging increased incentive spirometer use is not the priority in this situation as it does not address the immediate need for airway clearance. Option B) Encouraging the patient to increase oral fluid intake may not be effective in clearing the secretions that are causing the coarse crackles. Option D) Preoxygenating the patient for 3 minutes before suctioning is not the correct action to take when immediate airway clearance is needed due to the presence of secretions. In an educational context, it is crucial for nurses to understand the significance of auscultation findings like coarse crackles in patients with tracheostomy tubes. Prompt and appropriate intervention, such as sterile suctioning, is essential in maintaining airway patency and preventing respiratory complications in patients with compromised airways. Nurses must be skilled in performing suctioning procedures safely and effectively to provide optimal care for patients with tracheostomies.

Correct Answer: B

Rationale: The correct answer is B) "I will continue to do deep breathing and coughing exercises at home" because this statement demonstrates an understanding of the importance of lung expansion and clearance in pneumonia recovery. Deep breathing and coughing exercises help prevent complications such as atelectasis and pneumonia recurrence by promoting the clearance of secretions from the lungs. This indicates the patient's commitment to actively participating in their recovery process. Option A is incorrect because feeling tired after a week may not necessarily indicate a need to call the healthcare provider unless accompanied by other concerning symptoms. Option C is incorrect as scheduling appointments for vaccines, while important for prevention, does not directly relate to post-pneumonia care. Option D is incorrect because canceling a follow-up chest x-ray appointment based solely on feeling better does not account for the need to ensure complete resolution of the infection and lung healing. In an educational context, understanding the rationale behind post-pneumonia care instructions is crucial for patients to actively engage in their recovery and prevent complications. By explaining the importance of specific actions like deep breathing and coughing exercises, educators can empower patients to take ownership of their health and well-being, leading to better outcomes and reduced hospital readmission rates.

Correct Answer: B

Rationale: In preparing a patient for a thoracentesis, the correct action is to position the patient sitting up on the side of the bed. This position facilitates access to the pleural space, allowing for easier insertion of the needle and reducing the risk of complications such as pneumothorax. Option A (Starting a peripheral IV line to administer sedatives) is incorrect because sedation is not routinely required for a thoracentesis procedure, and starting an IV line solely for this purpose may not be necessary and could increase the patient's discomfort. Option C (Obtaining a collection device to hold 3 liters of pleural fluid) is incorrect because thoracentesis typically does not involve removing such a large volume of fluid. This option demonstrates a lack of understanding of the procedure and may cause unnecessary anxiety for the patient. Option D (Reminding the patient not to eat or drink anything for 6 hours) is incorrect because fasting is not typically required for a thoracentesis. This instruction is more commonly associated with procedures requiring anesthesia. Providing this information may confuse the patient and is not relevant to the preparation for a thoracentesis. Educationally, understanding the rationale behind preparing a patient for a thoracentesis is crucial for nurses to ensure the safety and comfort of the patient during the procedure. By knowing the correct position for the patient, nurses can help facilitate a successful thoracentesis while minimizing potential risks and complications. It is essential for nurses to have a sound understanding of the rationale behind each step in patient preparation to provide quality care in clinical settings.