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 correct answer is B) Kussmaul respirations. In this scenario, the patient's ABG results show a low pH and low HCO₃⁻ levels, indicating metabolic acidosis. Kussmaul respirations are a compensatory mechanism the body uses to try to lower the acidity in the blood by blowing off excess CO₂ through rapid and deep breathing. This is commonly seen in conditions like diabetic ketoacidosis, where the body is trying to correct the acid-base imbalance. Option A) Intercostal retractions are not typically associated with the ABG results provided in the question. Intercostal retractions are usually seen in conditions where there is increased work of breathing, such as respiratory distress or obstruction. Option C) Low oxygen saturation (SpO₂) is not specifically indicated by the ABG results provided. While the PaO₂ is 85 mm Hg, which is slightly on the lower side, it does not directly correlate with low oxygen saturation. Option D) Decreased venous O₂ pressure is not a typical finding related to the ABG results provided. Venous O₂ pressure is not directly assessed through arterial blood gas measurements and is not relevant in this context. Educationally, understanding how to interpret ABG results is crucial for nurses to provide safe and effective care to their patients. Recognizing the significance of findings like pH, PaCO₂, PaO₂, and HCO₃⁻ can help nurses identify potential underlying conditions and provide appropriate interventions to manage these conditions effectively.