A nurse is caring for a patient with a history of hypertension who is complaining of chest pain. What is the priority action?

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Question 1 of 5

A nurse is caring for a patient with a history of hypertension who is complaining of chest pain. What is the priority action?

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. Nitroglycerin is the priority action for chest pain in a patient with a history of hypertension as it helps dilate blood vessels, reducing cardiac workload and improving blood flow to the heart. This can help alleviate chest pain in the setting of a possible myocardial infarction. Aspirin (B) is also commonly given to patients with chest pain to prevent clot formation, but nitroglycerin takes precedence in this scenario. Sublingual nitroglycerin (C) is specifically mentioned as the correct choice, as it is a rapid-acting form of the medication. Corticosteroids (D) are not indicated for the immediate management of chest pain in this context.

Question 2 of 5

After the nurse has received change-of-shift report, which patient should the nurse assess first?

Correct Answer: C

Rationale: Post-bronchoscopy patients are at risk for complications like bleeding or airway issues, requiring priority assessment.

Question 3 of 5

After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider?

Correct Answer: A

Rationale: Clear nasal drainage could indicate cerebrospinal fluid leak, a serious complication requiring urgent reporting.

Question 4 of 5

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take?

Correct Answer: B

Rationale: Pain management is priority to improve breathing effort and prevent complications; morphine addresses the severe pain.

Question 5 of 5

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?

Correct Answer: C

Rationale: Cough suppressants may relieve a nonproductive cough, but their use must be balanced to avoid suppressing airway clearance.

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