A nurse is caring for a patient with severe burns. The patient is at risk for fluid volume deficit. What is the priority nursing action?

Correct Answer: A

Rationale: The correct answer is A. Administering intravenous fluids is the priority nursing action for a patient at risk for fluid volume deficit due to severe burns. This helps restore fluid balance and prevent complications like hypovolemic shock. Monitoring respiratory status (B) is important but not the priority in this case. Administering oral antibiotics (C) may be necessary but does not address the immediate risk of fluid deficit. Providing family support (D) is essential but not the priority when the patient's physiological needs must be addressed first.

Correct Answer: C

Rationale: The correct answer is C: Monitor the patient's blood glucose levels. This is the priority action because blurred vision can be a sign of uncontrolled blood glucose levels in diabetic patients. By monitoring the patient's blood glucose levels, the nurse can assess if the blurred vision is related to high or low blood sugar levels, and take appropriate actions such as administering insulin or providing glucose if needed. Checking the blood glucose level (choice A) is a single-point assessment and may not provide the full picture. Monitoring blood glucose levels (choice B) is repetitive and not specific to the current complaint. Administering intravenous fluids (choice D) is not necessary unless the patient is severely dehydrated, which is not indicated by the complaint of blurred vision.

Correct Answer: B

Rationale: The correct answer is B: Administer soft foods and fluids. This is the priority action because the patient is experiencing difficulty swallowing, which can lead to aspiration and further complications. Soft foods and fluids are easier for the patient to swallow safely. Administering thickened liquids (choice A) can still pose a risk of aspiration. Administering antihypertensive medications (choice C) is not the priority in this situation. Administering IV fluids (choice D) may not address the immediate issue of difficulty swallowing.

Correct Answer: C

Rationale: The correct answer is C: Perform chest physiotherapy. Shortness of breath in a ventilated patient may be due to secretion accumulation in the airways. Performing chest physiotherapy helps to mobilize and clear secretions, improving ventilation. Checking ventilator settings (A) is important but not the priority when the patient is experiencing distress. Administering IV fluids (B and D) is not directly related to the respiratory distress and should not take precedence over addressing the immediate breathing issue.

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin is the priority intervention for a patient with a history of MI as it helps prevent further clot formation and reduces the risk of another cardiac event. Administering IV fluids (choices B and C) may be necessary depending on the patient's condition, but aspirin takes precedence to address the immediate cardiac issue. Administering morphine (choice D) is not the priority as it may mask symptoms and delay definitive treatment. Overall, the main goal in a patient with a history of MI is to prevent further clot formation and reduce the risk of complications, making aspirin the most appropriate intervention.