A nurse is caring for a patient with a history of hypertension. The patient is complaining of a headache. What should the nurse do first?

Correct Answer: B

Rationale: The correct answer is B: Monitor the patient's blood pressure. As the patient has a history of hypertension and is experiencing a headache, the nurse should first assess the current blood pressure to determine if the headache is related to hypertension. Monitoring the blood pressure provides immediate information on the patient's cardiovascular status. Checking the blood pressure (option A) may not provide ongoing assessment, administering a corticosteroid (option C) is not indicated for a headache without further evaluation, and administering intravenous fluids (option D) is not the priority without knowing the patient's current fluid status.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen therapy. In a patient with chronic heart failure experiencing shortness of breath, the priority intervention is to ensure adequate oxygenation to prevent further complications. Administering oxygen therapy helps improve oxygen levels, reducing the workload on the heart. This can alleviate symptoms and prevent worsening of the condition. Administering a bronchodilator (B) may help with bronchospasm but does not address the primary issue of oxygenation. Administering pain relief (C) may be important but not the priority in this case. Administering IV fluids (D) could potentially worsen the patient's heart failure symptoms by increasing fluid volume.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. The priority action in this scenario is to address the chest pain, which could be indicative of a myocardial infarction or heart attack. Nitroglycerin helps to dilate blood vessels, improve blood flow to the heart, and relieve chest pain. Administering nitroglycerin promptly can help alleviate the patient's symptoms and potentially prevent further cardiac damage. Choice B (Administer aspirin) is also a common intervention for chest pain, but nitroglycerin is the priority as it directly addresses the underlying cause of chest pain in this case. Choice C (Monitor vital signs) and choice D (Administer IV fluids) are important interventions but are not the priority when a patient with a history of hypertension presents with chest pain, as addressing the potential cardiac issue should be the primary focus.

Correct Answer: C

Rationale: The correct answer is C: Administer oxygen therapy. Priority intervention is ensuring adequate oxygenation to the patient recovering from surgery. Oxygen therapy helps improve oxygen levels, vital for proper healing and recovery. Administering diuretics (A) is not a priority as the patient's pain needs immediate attention. IV fluids (B) may be necessary, but addressing pain and oxygenation come first. Administering antibiotics (D) is not indicated if the primary concern is pain and oxygen levels.

Correct Answer: B

Rationale: The ABG results indicate metabolic acidosis (low pH, low HCO₃⁻); Kussmaul respirations are a compensatory mechanism seen in diabetic ketoacidosis.