A patient recovering from a thoracotomy reports pain rated at 8/10. Which action should the nurse take first?

Correct Answer: A

Rationale: Rationale: The correct action for the nurse to take first in this scenario is option A, which is to administer prescribed pain medication. Pain management is crucial in post-operative care, especially in patients recovering from a thoracotomy. Severe pain can lead to physiological responses such as shallow breathing, which can compromise oxygenation. By addressing the pain promptly, the nurse can help the patient achieve adequate ventilation and oxygenation, promoting better recovery outcomes. Option B, assisting the patient with deep breathing exercises, is important for promoting lung expansion and preventing atelectasis. However, in this case, addressing the severe pain takes precedence as it can hinder the patient's ability to effectively participate in deep breathing exercises. Encouraging the use of the incentive spirometer, option C, is beneficial for improving lung function and preventing complications like pneumonia. However, if the patient is in severe pain, they may not be able to effectively utilize the spirometer due to discomfort. Repositioning the patient to relieve discomfort, option D, is a good nursing intervention for comfort. Still, in this situation, addressing the pain with medication is the priority to ensure the patient's overall well-being and ability to participate in other essential interventions for optimal oxygenation. In an educational context, this question highlights the importance of prioritizing nursing interventions based on the patient's immediate needs. It emphasizes the significance of pain management in post-operative care and the impact it can have on oxygenation and overall patient outcomes.

Correct Answer: B

Rationale: The correct answer is B) Administer an intravenous antihypertensive in a hypertensive crisis for a patient with a history of hypertension and diabetes. In this scenario, the priority is to lower the dangerously high blood pressure to prevent complications like stroke, heart attack, or organ damage. Administering an intravenous antihypertensive medication provides a rapid onset of action to quickly lower blood pressure and stabilize the patient's condition. Option A) Administer antihypertensive medication is incorrect because in a hypertensive crisis, the need for immediate blood pressure reduction requires a faster route of administration like intravenous over oral medications. Option C) Monitor the patient's blood pressure is incorrect as it does not address the immediate need to lower the dangerously high blood pressure. Option D) Monitor the patient for signs of renal failure is incorrect as it is important but not the priority in this acute situation. The focus should be on stabilizing the blood pressure first. In an educational context, it is crucial for nurses and healthcare providers to understand the urgency and priority of interventions in critical situations like hypertensive crises to provide timely and effective care to prevent complications and ensure patient safety.

Correct Answer: A

Rationale: In this scenario, the priority intervention for a patient who has just had a coronary artery bypass graft (CABG) is to monitor cardiac output (Option A). This is the correct answer because after CABG surgery, ensuring adequate cardiac output is crucial for the patient's overall hemodynamic stability and recovery. By closely monitoring cardiac output, the nurse can assess the heart's ability to pump effectively and detect any signs of decreased perfusion or cardiac complications early on. Option B, administering intravenous fluids, is not the priority intervention in this case because blindly giving fluids without assessing the patient's cardiac function can potentially worsen the patient's condition, especially if there are underlying cardiac issues. Option C, monitoring the patient's INR level, is not the priority immediately after CABG surgery. While monitoring coagulation levels is important for patients on anticoagulant therapy, it is not the most critical intervention right after surgery when cardiac output and perfusion need to be closely monitored. Option D, monitoring for complications, is important but is not the priority over monitoring cardiac output in the immediate post-operative period. While complications need to be monitored for, ensuring adequate cardiac output takes precedence to prevent further complications related to inadequate perfusion. In an educational context, understanding the rationale behind prioritizing interventions post-CABG surgery is essential for nurses to provide safe and effective care to their patients. By prioritizing monitoring cardiac output, nurses can promptly identify and address any cardiac-related issues, ultimately contributing to better patient outcomes and recovery.

Correct Answer: A

Rationale: The correct answer is A) Teach the patient to keep the mask on during meals. This is important because interrupting oxygen therapy during meals can lead to a decrease in oxygen saturation levels, potentially causing hypoxia in the patient. Maintaining consistent oxygen delivery is crucial for patients who require supplemental oxygen to support their oxygenation needs. Option B) Keep the air entrainment ports clean and unobstructed, although important for maintaining the functionality of the Venturi mask, is not directly related to ensuring the correct amount of oxygen delivery in this specific scenario. Option C) Giving a high enough flow rate to keep the bag from collapsing is not necessary with a Venturi mask, as the device is designed to deliver a precise oxygen concentration regardless of the flow rate. Option D) Draining moisture condensation from the corrugated tubing every hour is important for preventing infection and maintaining the integrity of the equipment but does not directly impact the correct amount of oxygen delivery in this case. In an educational context, it is crucial for nurses to understand the principles of oxygen therapy and how to ensure appropriate oxygen delivery to patients. Teaching patients about the importance of consistent oxygen therapy, especially during meals, is a key aspect of providing safe and effective care to individuals requiring oxygen supplementation.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Administer pain medications. The priority in this situation is to address the patient's severe pain to ensure their comfort and well-being. Pain management is a crucial aspect of postoperative care as uncontrolled pain can lead to various complications and adversely affect the patient's recovery process. Option B) Administer subcutaneous insulin is incorrect as it is not the priority at this moment. While managing blood glucose levels is important in a postoperative patient, addressing severe pain takes precedence in this case. Option C) Administer pain relief is vague and does not specify a concrete action. Administering pain relief can encompass various interventions, but the priority is to provide pain medications promptly in this immediate situation. Option D) Monitor the patient's blood glucose levels is also not the priority when the patient is experiencing severe pain. While monitoring blood glucose levels is essential, it can be done after addressing the immediate concern of pain management. From an educational perspective, it is important for nurses to prioritize patient care based on the principle of addressing the most critical needs first. Understanding the hierarchy of needs helps nurses make informed decisions in providing safe and effective care to their patients. Prompt pain management is crucial in enhancing patient comfort, promoting recovery, and ensuring overall patient satisfaction.