A nurse is caring for a patient with a history of heart failure. The nurse should prioritize which of the following interventions?

Correct Answer: A

Rationale: The correct answer is A: Administering diuretics to manage fluid retention. In heart failure, fluid overload can worsen symptoms and lead to complications. Diuretics help reduce excess fluid in the body, relieving strain on the heart. This intervention helps improve cardiac function and alleviate symptoms. Choice B (Encouraging increased physical activity) may be beneficial in some cases, but in heart failure, excessive physical activity can strain the heart further. Choice C (Providing a low-sodium diet) is important in managing heart failure, but diuretics would be more critical initially to address immediate fluid retention. Choice D (Encouraging high-potassium foods) is important for overall health but not the priority in managing heart failure.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions as it helps to reverse the symptoms quickly and prevent further complications. Administering corticosteroids (B) may be considered later for long-term management, but epinephrine is the immediate priority. Administering oxygen (C) may help with respiratory distress but does not address the underlying allergic reaction. Applying a cold compress (D) may provide temporary relief for local reactions but is not effective for a severe systemic allergic reaction.

Correct Answer: A

Rationale: The correct answer is A: Apply a traction splint. The priority for a client with a fractured femur is to immobilize the fracture to prevent further injury and reduce pain. Applying a traction splint helps stabilize the fracture and reduce risk of complications such as nerve or blood vessel damage. Administering pain medication (B) is important but not the priority. Placing the client in a supine position (C) may be needed for comfort but does not address the primary concern of stabilizing the fracture. Administering IV antibiotics (D) is not necessary for a fractured femur unless there are signs of infection.

Correct Answer: A

Rationale: The correct answer is A: Neutropenia. Neutropenia is a common side effect of chemotherapy where there is a decrease in neutrophil count, increasing the risk of infections. Monitoring for neutropenia is crucial to prevent serious infections and sepsis in chemotherapy patients. Hyperkalemia (B), chronic pain (C), and hypertension (D) are not direct complications of chemotherapy and do not pose immediate life-threatening risks to patients undergoing chemotherapy. Monitoring for neutropenia takes precedence due to the potential for life-threatening infections in immunocompromised patients.

Correct Answer: D

Rationale: The correct answer is D because it directly asks for specific information about past hospitalizations, prompting Mr. Y to recall the last time he was admitted for chest pain. This question is open-ended, allowing Mr. Y to provide detailed information voluntarily. A is incorrect as it assumes Mr. Y has been hospitalized without directly asking for that information. B is a better choice but lacks specificity in requesting details about past hospitalizations. C is inappropriate as it assumes permission to access medical records without Mr. Y's consent.

Correct Answer: C

Rationale: The correct answer is C: Assessing the patient's respiratory status. After administering pain medication, especially opioids, it is crucial to monitor the patient's respiratory status due to the risk of respiratory depression. This assessment is a priority because respiratory depression can be life-threatening. Other choices are not as immediate: A, assessing for addiction, can be done but is not as critical at this moment; B, assessing pain level, is important but comes after ensuring the patient's safety; D, assessing for infection, is not directly related to the immediate effects of pain medication.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. The first step in managing an asthma attack is to address the underlying cause, which is airway constriction. Bronchodilators help relax the muscles around the airways, making it easier for the client to breathe. Providing oxygen therapy (B) can be helpful but addressing airway constriction is the priority. Administering analgesics (C) or pain medication (D) is not appropriate as asthma attacks are not typically associated with pain.

Correct Answer: B

Rationale: The correct answer is B: Hamburgers. Clients with hypercholesterolemia should decrease their intake of saturated fats and cholesterol. Hamburgers are typically high in saturated fats and cholesterol due to the ground beef patty and cheese. Broiled catfish (A) is a lean protein source and can be a healthier option. Wheat bread (C) is a good source of fiber and can help lower cholesterol levels. Fresh apples (D) are a healthy choice low in saturated fats and cholesterol. Therefore, hamburgers should be decreased in the diet to manage hypercholesterolemia effectively.

Correct Answer: B

Rationale: The correct assessment is B because providing consistent information indicates reliability. Drug abuse history (A) does not necessarily mean the patient is unreliable. Smiling (C) is not a reliable indicator. Refusal to answer specific questions (D) does not negate overall reliability.