A nurse is caring for a patient with a history of stroke who is experiencing difficulty swallowing. What is the priority action?

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: 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.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Yellow-tinged sclera. This finding suggests jaundice, which can be a sign of hepatotoxicity, a potential adverse effect of anti-TB medications like isoniazid or rifampin. Jaundice indicates liver dysfunction, which can be serious and requires immediate medical attention to prevent further complications. Option B) Orange-colored sputum is not typically associated with TB medication side effects. It could be indicative of other conditions like chronic bronchitis or pneumonia, but it is not a direct concern related to TB drug therapy. Option C) Thickening of the fingernails is not a common side effect of TB medications and is more likely related to other factors such as aging, nutritional deficiencies, or fungal infections. It is not a critical finding that requires immediate notification of the healthcare provider. Option D) Difficulty hearing high-pitched voices is not a known side effect of TB medications. It could be related to age-related hearing loss or other ear-related issues but is not directly linked to the medication regimen for TB. Educationally, understanding the potential side effects of medications used in TB treatment is vital for nurses caring for patients with tuberculosis. Recognizing early signs of adverse reactions can prevent serious complications and improve patient outcomes. This question highlights the importance of thorough assessment skills and knowledge of medication side effects in providing safe and effective care to patients with TB.