A patient who had a total knee replacement is complaining of severe pain in the surgical site. What is the priority intervention?

Correct Answer: D

Rationale: The correct answer is D: Administer IV fluids. Severe pain post total knee replacement may indicate hypovolemia due to blood loss during surgery. Administering IV fluids will help restore circulating volume and improve perfusion to the surgical site. Analgesics can address pain but addressing the underlying cause is more important. Early ambulation and dressing change can be important but are not the priority in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Administer antiemetics. This is the priority intervention because nausea and vomiting can lead to complications such as dehydration and electrolyte imbalances postoperatively. Administering antiemetics helps to alleviate the symptoms and prevent further issues. Increasing fluid intake (B) is important but not the priority when the patient is actively experiencing nausea and vomiting. Monitoring respiratory status (C) and encouraging deep breathing (D) are important for overall postoperative care but do not directly address the immediate issue of nausea and vomiting.

Correct Answer: D

Rationale: The correct answer is D: Administer an antiemetic. This is the priority intervention because antiemetics help control nausea and vomiting, which are common side effects of chemotherapy. By addressing the symptoms promptly, the patient's comfort and quality of life can be improved. Administering IV fluids (choice B) may be necessary to prevent dehydration, but addressing the nausea and vomiting is the priority. Administering antibiotics (choice C) is not indicated unless there is a specific infection that requires treatment. Administering antiemetic medications (choice A) is redundant since the patient is already experiencing nausea and vomiting and needs immediate relief.

Correct Answer: A

Rationale: The correct answer is A: Administer antiemetic medications. The priority action for a patient experiencing nausea from chemotherapy is to address the symptom directly. Administering antiemetic medications helps alleviate nausea and prevent vomiting, improving the patient's comfort and adherence to treatment. Option B (short-acting bronchodilator) is not relevant to managing nausea. Option C (pain relief) is not the priority when the patient's main symptom is nausea. Option D (platelet aggregation inhibitor) is not indicated for nausea related to chemotherapy. Administering antiemetic medications aligns with the nursing priority of addressing immediate patient needs and promoting comfort during treatment.

Correct Answer: C

Rationale: The correct answer is C: Administer insulin therapy. The priority action in this scenario is to address the patient's wheezing due to asthma. Administering insulin therapy would be incorrect as it is not relevant to the patient's current condition. Administering insulin for elevated blood glucose levels would also be incorrect as the patient's primary issue is wheezing, not high blood sugar. Administering pain medication is not the priority as it does not address the underlying cause of wheezing in a patient with asthma. Therefore, the priority action is to provide appropriate asthma treatment to alleviate the wheezing and ensure the patient's respiratory status is stabilized.