A nurse is caring for a patient with a history of diabetes. The patient reports feeling shaky. Which intervention should the nurse perform first?

Correct Answer: A

Rationale: The correct answer is A: Check the patient's blood glucose level. This is the first step because the patient's symptoms of feeling shaky could indicate hypoglycemia, a common complication of diabetes. By checking the blood glucose level, the nurse can confirm if the patient's symptoms are due to low blood sugar and then take appropriate action. Administering oral glucose would be the next step if the blood glucose level is low, as it helps raise blood sugar quickly. Administering a corticosteroid injection is not indicated for hypoglycemia and may cause a delay in addressing the immediate issue. Encouraging the patient to exercise is also not appropriate when the patient is experiencing symptoms of low blood sugar, as it could further decrease blood glucose levels.

Correct Answer: D

Rationale: The correct answer is D: Administer an oral anticoagulant. The priority intervention for a patient who has had a total knee replacement and is experiencing severe pain is to administer an oral anticoagulant. This is because after surgery, there is an increased risk of blood clots forming in the legs due to immobility, which can lead to serious complications like pulmonary embolism. Administering an oral anticoagulant helps prevent the formation of blood clots and reduces the risk of these complications. Summary: - Option A (Administer analgesics): While controlling pain is important, in this case, preventing blood clots is the priority. - Option B (Administer antibiotics): Antibiotics are not indicated unless there is an infection present. - Option C (Administer insulin therapy): Insulin therapy is not relevant in this scenario unless the patient has diabetes that requires management.

Correct Answer: C

Rationale: The correct answer is C: Reposition the patient to prevent aspiration. Aspiration is a serious risk for stroke patients, especially those with difficulty swallowing. Repositioning the patient can help prevent aspiration pneumonia. Performing a swallowing assessment (choice A) is important but repositioning for safety takes precedence. Physical therapy (choice B) is important but not the priority in this situation. Administering a short-acting beta-agonist (choice D) is not relevant to the immediate safety concern of preventing aspiration.

Correct Answer: A

Rationale: The correct answer is A: Assess the patient's neurological status. This is the first step to determine the patient's current condition, severity of the stroke, and any potential complications. The nurse needs to assess for any changes in neurological status, such as speech difficulties or weakness in limbs, to determine the appropriate course of action. Administering a vasopressor (B) could potentially worsen the patient's condition if not indicated. Administering IV morphine (C) or steroids (D) would not address the immediate need to assess the neurological status and may delay necessary interventions.

Correct Answer: D

Rationale: The correct answer is D: Administer IV morphine. In CKD, pain management is crucial due to complications like uremic neuropathy. Morphine is a common analgesic used in CKD patients. Administering diuretics (A) can worsen kidney function. Administering IV fluids (B) may further stress the kidneys. Administering corticosteroids (C) can exacerbate fluid retention and electrolyte imbalances in CKD patients.