A nurse is caring for a patient who has just had a stroke. What is the priority intervention?

Correct Answer: C

Rationale: The correct answer is C: Monitor vital signs frequently. The priority intervention after a stroke is to closely monitor vital signs to detect any signs of deterioration or complications early on. This helps in providing timely interventions to prevent further harm. Performing a neurological assessment (A) can be important but not the immediate priority. Administering clot-busting medications (B) should be done within a specific time frame and requires proper patient evaluation first. Administering intravenous fluids (D) may be necessary, but monitoring vital signs takes precedence to ensure the patient's stability.

Correct Answer: B

Rationale: The correct answer is B: Administer an opioid analgesic. The priority action for a patient with CKD experiencing fluid retention is to manage their pain with an opioid analgesic. Pain can exacerbate fluid retention by activating the sympathetic nervous system, leading to increased sodium and water retention. Administering an opioid analgesic can help alleviate the pain, reduce sympathetic activation, and potentially decrease fluid retention. Other choices are incorrect: A: Administer diuretics - While diuretics are commonly used for fluid retention in CKD, managing pain should take precedence in this scenario. C: Administer fluids and electrolytes - Administering more fluids can further worsen fluid retention in a patient with CKD. D: Administer a vasodilator - Vasodilators are not commonly used for fluid retention in CKD and may not address the underlying issue of pain.

Correct Answer: B

Rationale: The correct answer is B: Notify the healthcare provider. This is the priority intervention because postoperative nausea could indicate a serious complication that requires immediate attention from the healthcare provider. Administering antiemetics (A) may help relieve symptoms but does not address the underlying cause. Administering oral rehydration solutions (C) may be beneficial for dehydration but should not be the priority without knowing the cause of nausea. Administering a vasodilator (D) is not indicated for nausea and could potentially worsen the patient's condition.

Correct Answer: B

Rationale: The correct answer is B: Administer glucose for hypoglycemia. In a patient with a history of diabetes experiencing dizziness and lightheadedness, the priority action is to address hypoglycemia, which can be life-threatening if left untreated. Administering glucose will help raise the blood sugar levels quickly and resolve the symptoms. Administering insulin (choices A and C) would lower blood sugar levels further, worsening the symptoms. Choice D, administering glucose for hypoglycemia, is incorrect because giving additional glucose to a patient already experiencing hypoglycemia can lead to rebound hypoglycemia. Thus, the priority is to treat hypoglycemia promptly with glucose.

Correct Answer: B

Rationale: The correct answer is B: Administer IV fluids. In a patient with COPD experiencing shortness of breath and fatigue, priority action is to address potential dehydration which can worsen symptoms. IV fluids can help improve hydration status, support oxygen delivery, and decrease respiratory distress. Administering pain relief (choices A and C) is not the priority as the main concern is respiratory distress. Administering a nebulized bronchodilator (choice D) can be beneficial but addressing dehydration takes precedence to optimize respiratory function.