A nurse is caring for a patient who is recovering from surgery. The patient is experiencing hypothermia. What is the priority nursing action?

Correct Answer: A

Rationale: The correct answer is A: Administer warming measures. The priority nursing action for a patient experiencing hypothermia is to prevent further heat loss and actively rewarm the patient to restore normal body temperature. This is crucial to prevent complications such as cardiac arrhythmias and impaired immune function. Administering warming measures, such as using warming blankets, heating pads, warm IV fluids, and adjusting room temperature, helps to increase the patient's core body temperature. Administering oxygen therapy (B) may be necessary for other conditions but is not the priority in this scenario. Repositioning the patient (C) may help with comfort and circulation but does not address the underlying issue of hypothermia. Administering antipyretics (D) is used to reduce fever, not hypothermia, and would not be effective in this case.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen therapy. In a patient with heart failure experiencing shortness of breath and chest pain, oxygen therapy is crucial to improve oxygenation and relieve symptoms. Administering oxygen helps increase oxygen saturation levels, reducing the workload on the heart. This intervention takes priority as it addresses the immediate need for adequate oxygen supply to vital organs. Administering diuretics (B) may be necessary to address fluid overload in heart failure, but oxygen therapy takes precedence in this scenario. Administering corticosteroids (D) is not indicated for acute heart failure exacerbation. Choice C is a duplicate of the correct answer and does not provide any additional rationale.

Correct Answer: A

Rationale: The correct answer is A: Increase the oxygen flow rate. In COPD patients experiencing shortness of breath, ensuring adequate oxygenation is crucial. Step 1: Assess the patient's oxygen saturation levels. Step 2: If oxygen saturation is low, increasing the oxygen flow rate will help improve oxygenation. Step 3: Monitor the patient's response to the increased oxygen flow rate. Administering a nebulized bronchodilator (B) may also be beneficial but addressing hypoxemia is the priority. Monitoring respiratory status (C) is important but not the immediate action. Administering oxygen therapy (D) is vague and less specific than increasing oxygen flow rate.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen therapy. In CHF, shortness of breath is often due to inadequate oxygenation. Administering oxygen therapy helps improve oxygen levels, alleviating respiratory distress. Morphine (B) can depress respiratory drive, making the situation worse. Administering pain relief (C) is not the priority when the patient's breathing is compromised. Administering IV fluids (D) can worsen fluid overload in CHF, exacerbating symptoms. Overall, oxygen therapy directly addresses the patient's immediate need for improved oxygenation in CHF.

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin is indicated as a priority action for a patient exhibiting facial drooping, as it may suggest the patient is experiencing a potential stroke. Aspirin helps prevent blood clot formation, which is crucial in ischemic strokes. Immediate administration of aspirin can help reduce the risk of further clot formation and minimize potential brain damage. Administering nitroglycerin (choice B) is not appropriate for stroke management. Short-acting bronchodilators (choice C) are not relevant to the patient's presentation. Administering antibiotics (choice D) is not indicated unless there is a specific infection present.