A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. The patient's oxygen saturation is 87%. What is the priority action?

Correct Answer: C

Rationale: The correct answer is C: Administer oxygen therapy. In a patient with COPD and oxygen saturation of 87%, the priority action is to ensure adequate oxygenation. Administering oxygen therapy will help improve oxygen saturation levels and prevent hypoxemia. Increasing the flow rate of oxygen (choice A) may lead to oxygen toxicity. Administering a nebulized bronchodilator (choice B) can help with bronchodilation but does not address the immediate need for oxygenation. Administering corticosteroids (choice D) may be indicated for COPD exacerbations but is not the priority in this scenario.

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.

Correct Answer: C

Rationale: Coarse crackles indicate secretions; sterile suctioning is required to clear the airway effectively.