A nurse is caring for a patient who is receiving IV fluids and has a heart rate of 110 beats/min and a blood pressure of 90/50 mm Hg. What is the priority action?

Correct Answer: D

Rationale: The correct answer is D: Monitor the patient's oxygen saturation levels. The priority action is to assess the patient's oxygen saturation as the vital signs indicate potential hypoperfusion. This could be due to inadequate tissue oxygenation, which is critical to address to prevent further deterioration. Administering a vasopressor (A) may further decrease blood pressure. Administering a loop diuretic (B) is not appropriate as the patient is hypotensive. Administering short-acting insulin (C) is not indicated in this scenario. Monitoring oxygen saturation levels will provide crucial information on the patient's respiratory status and guide appropriate interventions.

Correct Answer: A

Rationale: The correct answer is A: Increase oxygen flow. In COPD, the priority is to maintain adequate oxygenation. Increasing oxygen flow helps improve oxygen saturation and relieve respiratory distress. Monitoring vital signs (B) is important but not the priority in this case. Administering insulin therapy (C and D) is irrelevant as it does not address the immediate respiratory needs of a patient with COPD.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In a patient with a history of MI complaining of shortness of breath, the priority is to ensure adequate oxygenation to prevent further cardiac complications. Administering oxygen will help improve oxygen saturation and reduce cardiac workload. Choice B (Administer a short-acting bronchodilator) is incorrect as bronchodilators are not the priority in this case. Choice C (Administer oxygen therapy) is essentially the same as the correct answer, but using the term "oxygen" alone is more specific and appropriate. Choice D (Administer antibiotics) is not indicated for shortness of breath in this context.

Correct Answer: B

Rationale: In the context of a patient presenting with acute shortness of breath, the correct action for the nurse to take during the initial assessment is option B) Briefly ask specific questions about this episode of respiratory distress. This is the most appropriate course of action because it allows the nurse to quickly gather crucial information related to the current episode of respiratory distress. This information is essential for guiding immediate care and interventions to address the patient's acute condition effectively. Option A) Asking the patient to lie down for a full physical assessment is not advisable in this situation as it delays the assessment of the acute issue and may worsen the patient's respiratory distress. Option C) Completing the admission database to check for allergies before treatment, while important, is not the priority during the initial assessment of a patient with acute shortness of breath. Option D) Delaying the physical assessment to first complete pulmonary function tests is also not appropriate as immediate interventions are needed to stabilize the patient's respiratory status. From an educational perspective, understanding the priority of actions in emergency situations such as acute shortness of breath is crucial for nurses. By prioritizing information gathering related to the current episode of distress, nurses can quickly initiate appropriate interventions to address the patient's immediate needs and ensure optimal outcomes. This rationale highlights the significance of rapid assessment and decision-making in emergency care scenarios, emphasizing the importance of focusing on the most critical aspects of patient assessment and management.

Correct Answer: B

Rationale: The correct answer is B: Identifying and avoiding environmental triggers are the best way to prevent symptoms of allergic rhinitis. In managing allergic rhinitis, it is crucial to educate patients on identifying and avoiding triggers as the primary strategy. By recognizing and staying away from allergens such as pollen, dust mites, pet dander, or mold, individuals can significantly reduce the occurrence and severity of their symptoms. This empowers patients to take an active role in managing their condition and promotes a proactive approach to minimize exposure to allergens. Option A is incorrect because oral antihistamines are more commonly used for symptom relief rather than prevention. They are typically taken as needed when symptoms arise, not as a preventive measure before the allergy season. Option C is incorrect because although hand washing is important for overall health and hygiene, it is not the primary method for preventing allergic rhinitis, which is triggered by environmental allergens rather than being contagious. Option D is incorrect because while corticosteroid nasal sprays are effective in reducing inflammation in the nasal passages, their systemic effects are minimal due to their localized action. They are considered safe for long-term use in managing allergic rhinitis and do not have significant systemic side effects that limit their use. Educationally, emphasizing the importance of trigger identification and avoidance empowers patients to proactively manage their condition and reduce the need for symptomatic relief medications. Teaching patients to create an allergen-free environment and make lifestyle modifications to minimize exposure can significantly improve their quality of life and reduce the impact of allergic rhinitis symptoms.