A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first?

Correct Answer: B

Rationale: In this scenario, the nurse should prioritize option B: Notify the patient's health care provider. This action is crucial because the patient is presenting with symptoms that are indicative of a possible pulmonary embolism, a serious condition that requires immediate medical attention. Contacting the healthcare provider allows for prompt assessment, further diagnostic testing, and initiation of appropriate treatment. Option A (Administer anticoagulant drug therapy) is incorrect because administering medication without a proper diagnosis and healthcare provider's orders can be dangerous and may worsen the patient's condition if the diagnosis is incorrect. Option C (Prepare patient for a spiral CT) is also incorrect as it involves a diagnostic procedure that should be ordered by the healthcare provider after assessment and evaluation. It is not the nurse's role to independently order diagnostic tests. Option D (Elevate the head of the bed to a semi-Fowler's position) is a supportive measure but is not the priority in this situation. The patient's critical condition requires immediate medical intervention. Educationally, this question highlights the importance of prioritizing patient care based on assessment findings and the urgency of the situation. Nurses need to recognize emergent situations, collaborate with healthcare providers, and follow proper protocols to ensure optimal patient outcomes.

Correct Answer: B

Rationale: In this scenario, the priority nursing intervention for a patient with a history of myocardial infarction (MI) is to administer a beta-blocker (Option B). The rationale behind choosing a beta-blocker as the correct answer is that it helps reduce the workload on the heart by slowing the heart rate and reducing blood pressure, thereby decreasing myocardial oxygen demand. This is crucial in the context of MI to prevent further damage to the heart muscle. Administering morphine (Option A) may be necessary for pain management in MI, but it is not the priority over stabilizing the patient's cardiovascular status. Administering oral rehydration solutions (Option C) may be important for hydration but does not address the immediate cardiac concern. Administering antiplatelet therapy (Option D) is essential for preventing clot formation in MI, but it is not the priority intervention compared to reducing the heart's workload. From an educational perspective, understanding the rationale behind prioritizing interventions in MI is crucial for nurses to provide effective and timely care to patients experiencing cardiovascular emergencies. Prioritizing interventions based on physiological needs and potential impact on patient outcomes is a fundamental aspect of nursing practice that ensures patient safety and optimal care delivery.

Correct Answer: B

Rationale: The correct answer is B) Administer morphine. In the context of a patient with a history of stroke presenting with weakness and difficulty speaking, these symptoms may indicate the presence of acute pain, possibly related to the stroke. Administering morphine is the priority action to help alleviate the patient's pain and distress, as untreated pain can lead to increased physiological stress and potential complications. Option A) Perform a neurological assessment is important but not the priority in this situation where addressing the patient's immediate distress is crucial. Option C) Monitor respiratory status and Option D) Monitor blood glucose levels are also important aspects of care but are secondary to addressing the patient's acute pain and distress. From an educational standpoint, this question highlights the importance of prioritizing patient care based on immediate needs and symptoms. It emphasizes the need for nurses to quickly identify and address acute issues to ensure patient comfort and prevent potential complications. It also underscores the significance of pain management in improving patient outcomes and quality of care.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Administer an antihypertensive. The priority action in a patient with hypoglycemia and a history of diabetes is to rule out other causes of symptoms before assuming it is solely related to blood sugar levels. Administering an antihypertensive can help in managing any potential hypertension, which is crucial in this situation. Administering glucose (Option A) could worsen the hypoglycemia if the patient's symptoms are not solely due to low blood sugar. Administering insulin (Option B) is not appropriate as it would further lower the blood sugar levels. Administering pain relief (Option C) is not the priority in this case unless pain is a known cause of the hypoglycemia. In an educational context, understanding the priority actions in emergency situations is crucial for nurses, especially when dealing with patients with complex medical histories like diabetes. It is essential to assess the patient comprehensively before initiating any interventions to ensure the best possible outcomes.

Correct Answer: C

Rationale: In this question on pulmonary spirometry testing, option C, "I will inhale deeply and blow out hard during the test," indicates effective teaching by the nurse. This statement shows the patient understands the technique required for spirometry testing, which involves taking a deep breath and then exhaling forcefully into the spirometer to measure lung function accurately. Option A is incorrect because using an inhaler right before the test can affect the test results by altering the baseline lung function. Option B is incorrect as fasting before spirometry testing is not necessary. Option D is incorrect as blood pressure and pulse monitoring are not typically part of routine spirometry testing unless there are specific health concerns. Educationally, it is crucial for patients to understand the correct technique for spirometry testing to ensure accurate results. By teaching patients the correct procedure, nurses empower them to actively participate in their healthcare and obtain reliable diagnostic information for better treatment outcomes. Understanding the rationale behind the correct technique enhances patient compliance and cooperation during testing, leading to improved overall healthcare management.