The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide first?

Correct Answer: A

Rationale: The correct answer is A: Perform hand hygiene. Hand hygiene is essential to prevent the spread of infection when assisting a patient with a procedure. Before touching the incentive spirometer or interacting with the patient, the nurse must wash their hands thoroughly. This step ensures patient safety and reduces the risk of introducing harmful pathogens. Summary: B: Explaining the use of the mouthpiece is important but comes after ensuring proper hand hygiene. C: Instructing the patient to inhale slowly is a crucial step in using the incentive spirometer but should follow hand hygiene. D: Placing the patient in the reverse Trendelenburg position is not necessary for using the incentive spirometer and is not the priority in this situation.

Correct Answer: D

Rationale: The correct answer is D: Atropine. In third-degree AV block, the electrical signals from the atria to the ventricles are completely blocked. Atropine works by blocking the parasympathetic nervous system, which can further decrease the heart rate in a patient with bradycardia. In this scenario, avoiding Atropine is crucial to prevent worsening bradycardia. Epinephrine (A) and Dopamine (B) are sympathomimetic agents that can help increase heart rate and blood pressure, making them suitable choices in this situation. Dobutamine (C) is a positive inotrope that can increase heart contractility and may be beneficial in improving cardiac output in a hypotensive patient. In summary, Atropine should be avoided in a patient with third-degree AV block and symptomatic bradycardia to prevent further decreasing the heart rate, while the other options can be considered to help improve hem

Correct Answer: C

Rationale: The correct answer is C: Hydrocortisone. In anaphylaxis, hypotension can be caused by a massive release of inflammatory mediators. Hydrocortisone, a corticosteroid, helps reduce inflammation and stabilize blood pressure by modulating the immune response. It is often used as an adjuvant therapy in anaphylaxis when epinephrine alone is not effective. A: Cimetidine is an H2 receptor antagonist used for stomach acid-related issues, not for treating anaphylaxis-induced hypotension. B: Albuterol is a bronchodilator used for respiratory symptoms in anaphylaxis, not for hypotension. D: Ipratropium is an anticholinergic bronchodilator, also not used for treating anaphylaxis-induced hypotension.

Correct Answer: C

Rationale: The correct answer is C: Kussmaul respirations. In diabetic ketoacidosis, the body compensates for metabolic acidosis by increasing the respiratory rate to blow off excess carbon dioxide and lower blood pH. Kussmaul respirations are deep, rapid, and labored breathing characteristic of this compensatory mechanism. Bradypnea (A) is slow breathing, which is not typical in diabetic ketoacidosis. Central neurogenic hyperventilation (B) is rapid, deep breathing caused by a neurologic issue, not commonly associated with diabetic ketoacidosis. Cheyne-Stokes respirations (D) are characterized by periods of deep breathing followed by apnea and are not typically seen in diabetic ketoacidosis.

Correct Answer: B

Rationale: Step 1: Chest pain that is not relieved by oxygen therapy alone suggests that the cause of the pain is not related to a lack of oxygen to the heart muscle. Step 2: Acute myocardial infarction (heart attack) is caused by a blockage in the coronary arteries, leading to reduced blood flow and oxygen to the heart muscle. Step 3: If the chest pain is not affected by oxygen therapy, it indicates that the pain is likely due to a problem other than lack of oxygen, such as a heart attack. Step 4: Therefore, choice B is the correct answer as it points to a symptom consistent with an acute myocardial infarction. Summary: Choices A and C mention relief or lack of relief of chest pain with nitroglycerin, which is typically used for angina and may not necessarily indicate a heart attack. Choice D, cyanosis, is a late sign of inadequate oxygenation and not specific to an acute myocardial infarction