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

Correct Answer: B

Rationale: In this scenario, the priority nursing intervention for a patient with a history of myocardial infarction (MI) is to administer a beta-blocker (Option B). The rationale behind choosing a beta-blocker as the correct answer is that it helps reduce the workload on the heart by slowing the heart rate and reducing blood pressure, thereby decreasing myocardial oxygen demand. This is crucial in the context of MI to prevent further damage to the heart muscle. Administering morphine (Option A) may be necessary for pain management in MI, but it is not the priority over stabilizing the patient's cardiovascular status. Administering oral rehydration solutions (Option C) may be important for hydration but does not address the immediate cardiac concern. Administering antiplatelet therapy (Option D) is essential for preventing clot formation in MI, but it is not the priority intervention compared to reducing the heart's workload. From an educational perspective, understanding the rationale behind prioritizing interventions in MI is crucial for nurses to provide effective and timely care to patients experiencing cardiovascular emergencies. Prioritizing interventions based on physiological needs and potential impact on patient outcomes is a fundamental aspect of nursing practice that ensures patient safety and optimal care delivery.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Administer an antihypertensive. The priority action in a patient with hypoglycemia and a history of diabetes is to rule out other causes of symptoms before assuming it is solely related to blood sugar levels. Administering an antihypertensive can help in managing any potential hypertension, which is crucial in this situation. Administering glucose (Option A) could worsen the hypoglycemia if the patient's symptoms are not solely due to low blood sugar. Administering insulin (Option B) is not appropriate as it would further lower the blood sugar levels. Administering pain relief (Option C) is not the priority in this case unless pain is a known cause of the hypoglycemia. In an educational context, understanding the priority actions in emergency situations is crucial for nurses, especially when dealing with patients with complex medical histories like diabetes. It is essential to assess the patient comprehensively before initiating any interventions to ensure the best possible outcomes.

Correct Answer: C

Rationale: In this question on pulmonary spirometry testing, option C, "I will inhale deeply and blow out hard during the test," indicates effective teaching by the nurse. This statement shows the patient understands the technique required for spirometry testing, which involves taking a deep breath and then exhaling forcefully into the spirometer to measure lung function accurately. Option A is incorrect because using an inhaler right before the test can affect the test results by altering the baseline lung function. Option B is incorrect as fasting before spirometry testing is not necessary. Option D is incorrect as blood pressure and pulse monitoring are not typically part of routine spirometry testing unless there are specific health concerns. Educationally, it is crucial for patients to understand the correct technique for spirometry testing to ensure accurate results. By teaching patients the correct procedure, nurses empower them to actively participate in their healthcare and obtain reliable diagnostic information for better treatment outcomes. Understanding the rationale behind the correct technique enhances patient compliance and cooperation during testing, leading to improved overall healthcare management.

Correct Answer: C

Rationale: In this scenario, option C is the correct answer. When the patient asks how to clean the tracheostomy stoma and tube, it indicates that the identified problem of hopelessness related to loss of control of personal care is resolving. This question assesses the patient's willingness to engage in self-care activities, demonstrating a return of autonomy and a sense of empowerment. Option A is incorrect because allowing the nurse to suction the tracheostomy does not necessarily reflect the patient's initiative in self-care. Option B is incorrect as reliance on the spouse for daily tracheostomy care does not indicate the patient's independence in managing personal care needs. Option D is also incorrect as using a communication board to request 'No Visitors' does not address the self-care aspect or reflect a positive change in the patient's attitude towards personal care. From an educational perspective, this question highlights the importance of assessing a patient's psychological response to physical changes and loss of control. It emphasizes the nurse's role in promoting patient independence and empowerment in self-care activities to enhance the patient's overall well-being and quality of life. Encouraging patients to ask questions and participate in their care can have a significant impact on their recovery and emotional state.

Correct Answer: C

Rationale: The correct answer is C) Explain that orange discolored urine and tears are normal while taking this medication. This response demonstrates accurate knowledge about rifampin, a medication commonly used to treat tuberculosis. Rifampin is known to cause harmless side effects such as orange discoloration of bodily fluids, including urine and tears. By explaining this to the patient, the nurse can alleviate concerns and provide reassurance, promoting medication adherence and patient education. Option A) Asking about visual changes in red-green color discrimination is unrelated to the side effects of rifampin and tuberculosis treatment, making this option incorrect. Option B) Inquiring about shortness of breath, hives, or itching is not relevant to the known side effects of rifampin, so this response is incorrect and could lead to unnecessary concern for the patient. Option D) Advising the patient to stop the drug and report symptoms to the healthcare provider is incorrect because the side effects of orange discoloration of urine and tears are expected with rifampin therapy and do not warrant discontinuation of the medication without proper assessment by a healthcare provider. In an educational context, understanding the side effects of medications is crucial for nurses to provide accurate information to patients. By explaining expected side effects like orange discoloration of bodily fluids, nurses can enhance patient understanding, compliance, and overall therapeutic outcomes.