A patient with a history of heart failure is complaining of shortness of breath and chest pain. What is the priority nursing intervention?

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen therapy. In a patient with heart failure experiencing shortness of breath and chest pain, oxygen therapy is crucial to improve oxygenation and relieve symptoms. Administering oxygen helps increase oxygen saturation levels, reducing the workload on the heart. This intervention takes priority as it addresses the immediate need for adequate oxygen supply to vital organs. Administering diuretics (B) may be necessary to address fluid overload in heart failure, but oxygen therapy takes precedence in this scenario. Administering corticosteroids (D) is not indicated for acute heart failure exacerbation. Choice C is a duplicate of the correct answer and does not provide any additional rationale.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen therapy. In CHF, shortness of breath is often due to inadequate oxygenation. Administering oxygen therapy helps improve oxygen levels, alleviating respiratory distress. Morphine (B) can depress respiratory drive, making the situation worse. Administering pain relief (C) is not the priority when the patient's breathing is compromised. Administering IV fluids (D) can worsen fluid overload in CHF, exacerbating symptoms. Overall, oxygen therapy directly addresses the patient's immediate need for improved oxygenation in CHF.

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin is indicated as a priority action for a patient exhibiting facial drooping, as it may suggest the patient is experiencing a potential stroke. Aspirin helps prevent blood clot formation, which is crucial in ischemic strokes. Immediate administration of aspirin can help reduce the risk of further clot formation and minimize potential brain damage. Administering nitroglycerin (choice B) is not appropriate for stroke management. Short-acting bronchodilators (choice C) are not relevant to the patient's presentation. Administering antibiotics (choice D) is not indicated unless there is a specific infection present.

Correct Answer: D

Rationale: In the context of nursing, the assessment finding of bilateral basilar crackles in an older patient indicates the need for immediate action because it suggests significant respiratory issues such as pulmonary edema or infection. Prompt intervention is crucial to prevent further deterioration and ensure patient safety. Option A, weak cough effort, while concerning, does not pose an immediate threat to the patient's well-being. It may indicate muscle weakness or neurological issues but does not require urgent action like bilateral basilar crackles do. Option B, barrel-shaped chest, is a chronic finding commonly seen in patients with conditions like COPD. While it warrants monitoring and management, it does not necessitate immediate action as it is not an acute change in the patient's condition. Option C, dry mucous membranes, can indicate dehydration or inadequate fluid intake. While important to address, it does not pose an immediate life-threatening risk compared to the respiratory compromise indicated by bilateral basilar crackles. Educationally, understanding the significance of different assessment findings in older patients is vital for nurses to provide timely and appropriate care. This case underscores the importance of prioritizing assessments based on the urgency of the situation and acting quickly to address critical issues that may arise in the care of older adults with complex health needs.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Suction the tracheostomy when directed. This task falls within the scope of practice for an experienced LPN/LVN. Suctioning a tracheostomy requires skill and precision to maintain airway patency and prevent complications such as mucus plugging or respiratory distress. LPNs/LVNs are trained to perform this procedure safely under the guidance and direction of an RN or physician. Option A, assessing the patient's risk for aspiration, involves critical thinking skills and complex decision-making that are typically within the RN's scope of practice. Delegating this task to an LPN/LVN may not be appropriate as it requires a higher level of clinical judgment. Option C, teaching the patient tracheostomy self-care, involves patient education and empowerment, which are often responsibilities of the RN who can provide comprehensive education and assess the patient's understanding and ability to perform self-care effectively. Option D, determining the need for tracheostomy tube replacement, is a decision that requires advanced assessment skills and clinical knowledge that are typically within the RN's scope of practice. This task involves evaluating the patient's condition, assessing the tracheostomy site, and making critical decisions regarding tube changes based on patient-specific factors. In an educational context, it is essential for healthcare professionals to understand their scope of practice and responsibilities when delegating tasks to ensure safe and effective patient care. By correctly assigning tasks based on individual competencies and regulations, the healthcare team can work collaboratively to provide optimal care for patients with complex needs, such as those with permanent tracheostomies.