A nurse is caring for a patient with a history of stroke. What is the priority nursing intervention?

Correct Answer: B

Rationale: The correct answer is B: Monitor the patient for changes in neurological status. This is the priority intervention because patients with a history of stroke are at risk for complications such as recurrent strokes or worsening neurological status. Monitoring for changes allows for early detection and timely intervention. A: Assisting with a swallowing assessment is important, but monitoring neurological status takes precedence as it directly assesses the patient's brain function. C: Having a family member for rehabilitation is beneficial but not the priority over monitoring neurological status for immediate complications. D: Providing medication for swallowing improvement may be necessary, but monitoring neurological status is crucial for detecting any emergent issues. In summary, monitoring neurological status is the priority as it directly assesses the patient's brain function and allows for early detection of complications.

Correct Answer: B

Rationale: The correct answer is B because a sudden onset of shortness of breath in a patient on bed rest may indicate a life-threatening condition like a pulmonary embolism or cardiac event. Assessing this patient first is crucial for prompt intervention. Choice A can wait as pulmonary function testing is a scheduled procedure. Choice C, the TB patient, can wait briefly as medications can be administered a bit later without immediate harm. Choice D, the patient with pneumonia and a low-grade fever, is stable and can be assessed after the patient with sudden shortness of breath.

Correct Answer: C

Rationale: The correct answer is C: Monitor the patient's blood glucose levels. This is the priority action because blurred vision can be a sign of uncontrolled blood glucose levels in diabetic patients. By monitoring the patient's blood glucose levels, the nurse can assess if the blurred vision is related to high or low blood sugar levels, and take appropriate actions such as administering insulin or providing glucose if needed. Checking the blood glucose level (choice A) is a single-point assessment and may not provide the full picture. Monitoring blood glucose levels (choice B) is repetitive and not specific to the current complaint. Administering intravenous fluids (choice D) is not necessary unless the patient is severely dehydrated, which is not indicated by the complaint of blurred vision.

Correct Answer: B

Rationale: The correct answer is B: Administer soft foods and fluids. This is the priority action because the patient is experiencing difficulty swallowing, which can lead to aspiration and further complications. Soft foods and fluids are easier for the patient to swallow safely. Administering thickened liquids (choice A) can still pose a risk of aspiration. Administering antihypertensive medications (choice C) is not the priority in this situation. Administering IV fluids (choice D) may not address the immediate issue of difficulty swallowing.

Correct Answer: C

Rationale: The correct answer is C: Perform chest physiotherapy. Shortness of breath in a ventilated patient may be due to secretion accumulation in the airways. Performing chest physiotherapy helps to mobilize and clear secretions, improving ventilation. Checking ventilator settings (A) is important but not the priority when the patient is experiencing distress. Administering IV fluids (B and D) is not directly related to the respiratory distress and should not take precedence over addressing the immediate breathing issue.