A nurse is caring for a patient with a history of myocardial infarction (MI) who is complaining of shortness of breath. What is the priority intervention?

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: 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.

Correct Answer: A

Rationale: In the context of oxygenation and respiratory health, understanding the assessment findings associated with specific respiratory conditions is crucial. In this case, the correct answer is A) Increased tactile fremitus when assessing a patient with pneumococcal pneumonia. Pneumococcal pneumonia typically causes consolidation in the lungs, which refers to the solidification of normally aerated lung tissue due to infection. This consolidation increases the transmission of vibrations through the lung tissue, leading to increased tactile fremitus upon palpation of the chest. Therefore, it is an expected finding in a patient with pneumococcal pneumonia. Now, let's explore why the other options are incorrect: - B) Dry, nonproductive cough: While cough is a common symptom of pneumonia, pneumococcal pneumonia typically presents with a productive cough, not a dry one. - C) Hyperresonance to percussion: Hyperresonance is associated with conditions like emphysema or pneumothorax, not with pneumonia involving lung consolidation. - D) A grating sound on auscultation: A grating sound, known as a pleural friction rub, is more commonly associated with conditions like pleurisy or pericarditis, not specifically with pneumococcal pneumonia. Educationally, understanding these nuanced respiratory assessment findings not only helps in clinical practice but also aids in critical thinking and clinical reasoning skills. By connecting pathophysiology with assessment findings, nurses can better prioritize care and interventions for patients with respiratory conditions like pneumonia. This knowledge is essential for success on exams like the NCLEX and for providing safe and effective patient care in practice.

Correct Answer: A

Rationale: The correct answer to the question is A) Observe for distended neck veins. This assessment is crucial in evaluating the effectiveness of therapies for a patient with cor pulmonale and right-sided heart failure because distended neck veins are a classic sign of right-sided heart failure. By observing for reduced neck vein distension, the nurse can assess whether the prescribed therapies are effectively addressing the underlying issues causing the right-sided heart failure, such as pulmonary hypertension leading to cor pulmonale. Improved right heart function is a key goal in the treatment of these conditions. Option B) Auscultate for crackles in the lungs is incorrect because crackles in the lungs are more indicative of left-sided heart failure or respiratory issues, rather than directly reflecting the effectiveness of therapies on right-sided heart failure in cor pulmonale. Option C) Palpate for heaves or thrills over the heart is incorrect as heaves and thrills are more related to structural abnormalities or valvular issues of the heart, rather than specific to assessing right-sided heart failure in cor pulmonale. Option D) Monitor for elevated white blood cell count is incorrect because an elevated white blood cell count is a sign of infection or inflammatory response in the body, and is not directly related to assessing the effectiveness of therapies for right-sided heart failure in cor pulmonale. In an educational context, understanding the rationale behind why a specific assessment is used to evaluate the effectiveness of therapies is crucial for nursing students preparing for the NCLEX exam. It helps them develop critical thinking skills and clinical reasoning to make informed decisions in patient care. By grasping the pathophysiology of conditions like cor pulmonale and right-sided heart failure, students can apply their knowledge to select the most appropriate assessments and interventions to improve patient outcomes.

Correct Answer: D

Rationale: The correct answer is option D, the 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion, should be assessed first. Tracheal deviation indicates a potential tension pneumothorax, a critical condition where air accumulates in the pleural space under pressure, causing the lung to collapse and shifting the trachea. This situation can rapidly progress to respiratory failure and requires immediate intervention to prevent further complications, making prompt assessment crucial. Option A, the 72-year-old with cor pulmonale and bilateral edema, though concerning, does not present an immediate life-threatening condition that requires urgent assessment compared to tracheal deviation. Option B, the 28-year-old with a lung transplant and fever, may indicate infection but is not as acutely critical as tracheal deviation. Option C, the 40-year-old with pleural effusion and chest pain, while in discomfort, does not have a presentation as urgent as tracheal deviation. In an educational context, understanding the priority of patient assessment based on the urgency of their condition is essential for nurses. Recognizing critical signs like tracheal deviation and knowing the appropriate actions to take in such situations can significantly impact patient outcomes. This scenario highlights the importance of swift clinical judgment and prioritization in nursing practice to ensure timely and effective care delivery.