A nurse is caring for a patient with a history of diabetes who is complaining of blurred vision. What is the priority action?

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: 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.

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin is the priority intervention for a patient with a history of MI as it helps prevent further clot formation and reduces the risk of another cardiac event. Administering IV fluids (choices B and C) may be necessary depending on the patient's condition, but aspirin takes precedence to address the immediate cardiac issue. Administering morphine (choice D) is not the priority as it may mask symptoms and delay definitive treatment. Overall, the main goal in a patient with a history of MI is to prevent further clot formation and reduce the risk of complications, making aspirin the most appropriate intervention.

Correct Answer: B

Rationale: In this scenario, option B is the correct answer because listening only during the inspiratory phase and then moving the stethoscope misses out on important expiratory sounds, which are crucial for a comprehensive respiratory assessment. This indicates a need for the student to review their respiratory assessment skills to ensure a thorough examination. Option A is incorrect because comparing breath sounds from side to side at each level is a good practice in respiratory assessment to identify any asymmetry or abnormal findings. Option C is also incorrect as starting at the apices of the lungs and moving down towards the lung bases is a systematic and recommended approach for listening to lung sounds. Option D is incorrect because instructing the patient to breathe slowly and deeply through the mouth is a standard technique to ensure optimal lung sound auscultation and is not indicative of a need for review. In an educational context, understanding the importance of listening to both inspiratory and expiratory sounds during a respiratory assessment is vital for accurate diagnosis and monitoring of respiratory conditions. Students must be proficient in their assessment skills to provide high-quality care to patients with respiratory issues. Regular practice and feedback can help students refine their auscultation techniques and enhance their overall respiratory assessment competency.

Correct Answer: A

Rationale: The correct answer is A) "I must keep the stoma covered with an occlusive dressing." This statement indicates a need for additional instruction because an occlusive dressing could potentially block the stoma, leading to impaired breathing. Instead, a breathable cover should be used to protect the stoma without obstructing airflow. Option B) "I need to have smoke and carbon monoxide detectors installed" is a correct statement as these detectors are essential for the safety of a patient with a laryngectomy who may not be able to detect smoke or carbon monoxide by smell. Option C) "I can participate in my prior fitness activities except swimming" is also a correct statement because swimming can pose a risk of water entering the stoma and causing complications. Option D) "I should wear a Medic-Alert bracelet to identify me as a neck breather" is a correct statement as it is important for emergency responders to be aware of the patient's unique airway needs. Educationally, understanding the specific care needs of patients with a total laryngectomy is crucial for nurses. By providing accurate and clear discharge instructions, nurses can empower patients to manage their condition effectively at home and reduce the risk of complications. It is essential for nurses to impart this knowledge to ensure the safety and well-being of patients in their care.