A nurse is caring for a patient who has just had a coronary artery bypass graft (CABG). What is the priority intervention?

Correct Answer: A

Rationale: In this scenario, the priority intervention for a patient who has just had a coronary artery bypass graft (CABG) is to monitor cardiac output (Option A). This is the correct answer because after CABG surgery, ensuring adequate cardiac output is crucial for the patient's overall hemodynamic stability and recovery. By closely monitoring cardiac output, the nurse can assess the heart's ability to pump effectively and detect any signs of decreased perfusion or cardiac complications early on. Option B, administering intravenous fluids, is not the priority intervention in this case because blindly giving fluids without assessing the patient's cardiac function can potentially worsen the patient's condition, especially if there are underlying cardiac issues. Option C, monitoring the patient's INR level, is not the priority immediately after CABG surgery. While monitoring coagulation levels is important for patients on anticoagulant therapy, it is not the most critical intervention right after surgery when cardiac output and perfusion need to be closely monitored. Option D, monitoring for complications, is important but is not the priority over monitoring cardiac output in the immediate post-operative period. While complications need to be monitored for, ensuring adequate cardiac output takes precedence to prevent further complications related to inadequate perfusion. In an educational context, understanding the rationale behind prioritizing interventions post-CABG surgery is essential for nurses to provide safe and effective care to their patients. By prioritizing monitoring cardiac output, nurses can promptly identify and address any cardiac-related issues, ultimately contributing to better patient outcomes and recovery.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Administer pain medications. The priority in this situation is to address the patient's severe pain to ensure their comfort and well-being. Pain management is a crucial aspect of postoperative care as uncontrolled pain can lead to various complications and adversely affect the patient's recovery process. Option B) Administer subcutaneous insulin is incorrect as it is not the priority at this moment. While managing blood glucose levels is important in a postoperative patient, addressing severe pain takes precedence in this case. Option C) Administer pain relief is vague and does not specify a concrete action. Administering pain relief can encompass various interventions, but the priority is to provide pain medications promptly in this immediate situation. Option D) Monitor the patient's blood glucose levels is also not the priority when the patient is experiencing severe pain. While monitoring blood glucose levels is essential, it can be done after addressing the immediate concern of pain management. From an educational perspective, it is important for nurses to prioritize patient care based on the principle of addressing the most critical needs first. Understanding the hierarchy of needs helps nurses make informed decisions in providing safe and effective care to their patients. Prompt pain management is crucial in enhancing patient comfort, promoting recovery, and ensuring overall patient satisfaction.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Check the ventilator settings. This is the priority intervention because the patient's signs of respiratory distress indicate a potential issue with the mechanical ventilation. Checking the ventilator settings allows the nurse to assess if the settings are appropriate for the patient's current condition and make any necessary adjustments to improve oxygenation. Monitoring the patient's blood pressure (option B) is important in overall patient assessment, but in this case, addressing the respiratory distress takes precedence as it directly impacts oxygenation and can lead to serious complications if not managed promptly. Administering IV fluids (options C and D) is not the priority in this situation as the patient is experiencing respiratory distress, which requires immediate attention to ensure adequate oxygenation. IV fluids may be needed depending on the patient's overall condition, but addressing the respiratory distress should come first to prevent further deterioration. In an educational context, understanding the priority interventions in a critical care setting like mechanical ventilation is crucial for nurses to provide safe and effective care. By prioritizing actions based on the patient's condition, nurses can intervene promptly to optimize outcomes and prevent complications related to oxygenation.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Administer pain relief. The priority action for a patient with COPD experiencing pain is to provide pain relief to alleviate their discomfort. Pain can exacerbate respiratory distress in patients with COPD, leading to increased work of breathing and potential complications. Addressing pain promptly not only improves the patient's comfort but also supports their respiratory function. Option A) Administer oxygen therapy may seem like a logical choice, but in this case, addressing the patient's pain takes precedence over oxygen therapy as pain can worsen respiratory distress. Option B) Administer morphine for pain relief is incorrect as it duplicates the correct answer but adds a specific medication. Providing pain relief without specifying a medication allows for flexibility in choosing the most appropriate pain relief intervention based on the patient's individual needs and condition. Option D) Administer insulin therapy is irrelevant to the patient's immediate needs in managing COPD and is not a priority action in this situation. Educationally, understanding the priority of interventions in managing COPD is crucial for nurses caring for these patients. Pain management plays a significant role in improving patient outcomes and should be promptly addressed to enhance patient comfort and support respiratory function. Nurses must prioritize interventions based on the patient's condition and individual needs to provide safe and effective care.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Administer insulin. The priority action is to address the patient's complaint of blurry vision, which can be a sign of hyperglycemia in a patient with diabetes. Administering insulin is crucial to lower the elevated blood glucose levels that may be causing the blurry vision and prevent potential complications like diabetic retinopathy. Option A) Monitor blood glucose levels is not the priority in this situation because the patient is already experiencing symptoms of hyperglycemia, and prompt intervention is needed. Option B) Administer a nebulizer is not relevant to the patient's complaint of blurry vision, which is likely related to the uncontrolled blood glucose levels. Option D) Monitor vital signs is important but not the immediate priority when the patient is experiencing a symptom that indicates a potential diabetic emergency. Educationally, this question highlights the importance of recognizing early signs of hyperglycemia in patients with diabetes and the need for prompt intervention to prevent complications. Understanding the link between diabetes, hyperglycemia, and ocular complications is crucial for nurses to provide safe and effective care for diabetic patients.