A nurse is caring for a patient with a history of diabetes who is experiencing an acute episode of hyperglycemia. What is the priority action?

Correct Answer: A

Rationale: The correct answer is A: Administer insulin. In hyperglycemia, administering insulin is the priority as it helps lower blood glucose levels effectively. Insulin is essential in managing high blood sugar levels in diabetic patients. Administering subcutaneous insulin (choice B) may not act fast enough in acute situations. Administering intravenous fluids (choice C) can help with hydration but does not address the primary issue of high blood sugar. Administering fluids alone (choice D) does not directly address hyperglycemia. Therefore, administering insulin is the most crucial action to manage hyperglycemia effectively.

Correct Answer: C

Rationale: The correct answer is C: Administer insulin. The priority nursing action for a patient with dysphagia and a history of stroke is to address the potential cause, which could be hyperglycemia leading to diabetic dysphagia. Administering insulin would help control blood sugar levels, which could improve swallowing function. Administering thickened liquids (choice A) may help with dysphagia symptoms, but addressing the underlying cause is crucial. IV fluids (choice B) may not be necessary unless the patient is dehydrated. Administering pain medication (choice D) is not the priority unless pain is identified as the cause of dysphagia.

Correct Answer: B

Rationale: The correct answer is B: Administer IV fluids. The priority intervention for a patient with hypertension experiencing chest pain is to ensure adequate perfusion to vital organs. Administering IV fluids helps improve blood flow, stabilize blood pressure, and support cardiac function. This intervention is crucial in managing chest pain and preventing potential complications. Administering nitroglycerin (choice A) is important for chest pain relief but may cause a drop in blood pressure, which can be risky in patients with hypertension. Administering aspirin (choice C) is important for antiplatelet effects but does not address the immediate need for perfusion. Administering morphine (choice D) is used for pain relief but may mask symptoms and delay necessary interventions.

Correct Answer: D

Rationale: Elevating the head reduces swelling post-rhinoplasty, indicating effective teaching.

Correct Answer: A

Rationale: A weak cough effort directly impairs the ability to clear secretions from the airway, supporting the diagnosis of ineffective airway clearance.