A patient is experiencing an allergic reaction to penicillin. What is the priority nursing action?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Administer epinephrine. The priority in managing an allergic reaction, such as an anaphylactic reaction to penicillin, is to administer epinephrine promptly. Epinephrine is a life-saving medication that helps reverse severe allergic reactions by constricting blood vessels, increasing heart rate, and opening airways to improve breathing. Option A) Administering an antihistamine may help with mild allergic reactions, but in a severe reaction like anaphylaxis, it is not the first-line treatment. Option C) Administering a bronchodilator is more appropriate for respiratory conditions like asthma, not for an acute allergic reaction. Option D) Administering intravenous fluids may be necessary to support blood pressure in an anaphylactic reaction, but it is not the initial priority. In an educational context, it is crucial for nurses to understand the urgency of recognizing and managing allergic reactions effectively. Proper training and knowledge of medications like epinephrine and their indications in emergency situations can save lives. Nurses should always be prepared to act swiftly and decisively in such critical situations to provide optimal patient care.

Correct Answer: A

Rationale: In the context of caring for a patient with acute renal failure, the priority intervention is to administer IV fluids (Option A). The rationale behind this is that patients with acute renal failure often experience fluid imbalances, such as dehydration due to decreased urine output. Administering IV fluids helps to maintain adequate hydration, support renal function, and prevent further complications like electrolyte imbalances. Option B, administering IV fluids and electrolytes, may seem like a reasonable choice. However, in this scenario, the priority is to address the immediate need for fluid replacement. Once hydration status is stabilized, electrolyte replacement can be initiated as needed. Monitoring urine output (Option C) is important in the overall management of acute renal failure, but it is not the priority intervention in this case. Administering IV fluids takes precedence to address the immediate fluid imbalance. Administering a platelet inhibitor (Option D) is not indicated in the management of acute renal failure. Platelet inhibitors are used to prevent blood clot formation and are not directly related to the treatment of renal failure. In an educational context, understanding the priority interventions in the care of patients with specific conditions is crucial for nurses to provide safe and effective care. By prioritizing interventions based on the patient's condition and needs, nurses can optimize patient outcomes and prevent complications.

Correct Answer: D

Rationale: In this scenario, the correct intervention for a young adult patient with cystic fibrosis (CF) experiencing increased dyspnea is option D) Instruct the patient about pancreatic enzyme replacements. This is the correct choice because CF is a genetic disorder that affects multiple organ systems, including the pancreas. Patients with CF often have pancreatic insufficiency, leading to malabsorption of nutrients. Pancreatic enzyme replacements help these patients digest and absorb essential nutrients from food, improving overall health and respiratory function. Option A) Schedule a sweat chloride test is incorrect because this test is used to diagnose CF, not to address acute symptoms like increased dyspnea. Option B) Arrange for a hospice nurse visit is also incorrect as it is not appropriate for a young adult with CF who is experiencing increased dyspnea. Option C) Perform chest physiotherapy every 4 hours is not the priority intervention in this case, as addressing pancreatic insufficiency and ensuring proper nutrition is crucial for managing CF-related symptoms and preventing complications. Educationally, understanding the multi-system nature of CF is essential for nurses caring for these patients. It is important to prioritize interventions that address specific CF-related issues, such as pancreatic insufficiency, to optimize patient outcomes and quality of life. Providing education and support on pancreatic enzyme replacements empowers patients to manage their condition effectively and improve their overall health.

Correct Answer: C

Rationale: In this scenario, the priority nursing intervention is to perform a neurological exam (Option C). During an asthma attack, it is crucial to assess the patient's neurological status to determine the severity of the attack and whether there are any complications such as hypoxia or respiratory distress. By conducting a neurological exam, the nurse can evaluate the patient's level of consciousness, cognitive function, motor responses, and overall neurological status, which can guide further interventions and treatment. Administering a bronchodilator (Option A) may be necessary to help alleviate the asthma symptoms, but assessing the neurological status takes precedence as it provides critical information about the patient's condition and response to treatment. Administering sublingual nitroglycerin (Option B) is not indicated in the management of an asthma attack and could potentially worsen the patient's condition by causing systemic vasodilation. Monitoring the patient's oxygen saturation levels (Option D) is important in the overall management of asthma, but it is not the priority intervention in this acute situation. Assessing the patient's neurological status should come first to ensure timely and appropriate interventions are implemented. In an educational context, understanding the rationale behind prioritizing interventions in acute situations like asthma attacks is essential for nurses to provide safe and effective care. By prioritizing assessments and interventions based on the patient's condition, nurses can optimize outcomes and provide patient-centered care.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Perform a neurological exam. The priority action when a patient with a history of stroke complains of sudden weakness in the right arm is to assess the patient's neurological status to quickly determine if this weakness is indicative of a new stroke or worsening condition. Performing a neurological exam allows the nurse to assess for signs of a stroke, such as changes in motor strength, sensation, coordination, and speech. Early detection and intervention are crucial in stroke management to prevent further damage and improve outcomes. Administering morphine (option B) without assessing the patient's neurological status can mask symptoms and delay appropriate treatment. Reassuring the patient (option C) is important for emotional support but should not take precedence over a neurological assessment in this critical situation. Administering IV fluids (option D) is not the priority when a patient is presenting with potential stroke symptoms. Educationally, this question emphasizes the importance of prompt assessment and critical thinking in nursing practice, especially in situations where time is of the essence, such as when caring for patients with a history of stroke. Nurses must be able to prioritize actions based on the patient's condition and provide timely and appropriate interventions to ensure the best possible outcomes for their patients.