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

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. During the acute phase of myocardial infarction (MI), aspirin is crucial to reduce platelet aggregation and prevent further clot formation in the coronary arteries, reducing the risk of reinfarction. Aspirin helps improve blood flow to the heart muscle, minimizing damage. Thrombolytic therapy (choice B) is important but is typically given within the first few hours of symptom onset, not during the acute phase. Administering IV fluids (choice C) may be necessary for hemodynamic support but is not the priority intervention. Administering an oral anticoagulant (choice D) is not the initial priority in the acute phase of MI.

Correct Answer: B

Rationale: Correct Answer: B Rationale: Maintaining the patient in the lateral position for 20 minutes after postural drainage with percussion and vibration helps to facilitate drainage of secretions from the affected lung segments. This position helps to target specific lung segments and allows gravity to assist in moving secretions towards larger airways for easier expectoration. Incorrect Choices: A: Scheduling the procedure 1 hour after the patient eats is not necessary for postural drainage with percussion and vibration. It is more important to maintain the patient in the proper position for effective drainage. C: Giving albuterol before therapy is not directly related to postural drainage with percussion and vibration. Albuterol is a bronchodilator that may be prescribed for bronchospasm but is not directly related to postural drainage. D: Performing percussion before assisting the patient to the drainage position is incorrect. Percussion should be performed after the patient is in the appropriate position to facilitate secretion movement.

Correct Answer: B

Rationale: The correct answer is B: Administer an opioid analgesic. The priority action for a patient with CKD experiencing fluid retention is to manage their pain with an opioid analgesic. Pain can exacerbate fluid retention by activating the sympathetic nervous system, leading to increased sodium and water retention. Administering an opioid analgesic can help alleviate the pain, reduce sympathetic activation, and potentially decrease fluid retention. Other choices are incorrect: A: Administer diuretics - While diuretics are commonly used for fluid retention in CKD, managing pain should take precedence in this scenario. C: Administer fluids and electrolytes - Administering more fluids can further worsen fluid retention in a patient with CKD. D: Administer a vasodilator - Vasodilators are not commonly used for fluid retention in CKD and may not address the underlying issue of pain.

Correct Answer: B

Rationale: The correct answer is B: Notify the healthcare provider. This is the priority intervention because postoperative nausea could indicate a serious complication that requires immediate attention from the healthcare provider. Administering antiemetics (A) may help relieve symptoms but does not address the underlying cause. Administering oral rehydration solutions (C) may be beneficial for dehydration but should not be the priority without knowing the cause of nausea. Administering a vasodilator (D) is not indicated for nausea and could potentially worsen the patient's condition.

Correct Answer: B

Rationale: The correct answer is B: Administer glucose for hypoglycemia. In a patient with a history of diabetes experiencing dizziness and lightheadedness, the priority action is to address hypoglycemia, which can be life-threatening if left untreated. Administering glucose will help raise the blood sugar levels quickly and resolve the symptoms. Administering insulin (choices A and C) would lower blood sugar levels further, worsening the symptoms. Choice D, administering glucose for hypoglycemia, is incorrect because giving additional glucose to a patient already experiencing hypoglycemia can lead to rebound hypoglycemia. Thus, the priority is to treat hypoglycemia promptly with glucose.