The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first?

Correct Answer: C

Rationale: The correct answer is C: Positioning only on the right side. This is the first action the nurse should take because it helps improve ventilation-perfusion matching and oxygenation post-thoracotomy. By positioning the patient on the right side, gravity helps to optimize lung expansion on the unaffected side, improving gas exchange. Option A may be uncomfortable for the patient and not directly address the underlying issue. Option B is important but not the first priority in this scenario. Option D is also essential but positioning on the right side takes precedence in addressing the patient's immediate needs.

Correct Answer: A

Rationale: The correct answer is A: Administer a bronchodilator. This is the priority intervention because bronchodilators help to quickly open up the airways in asthma patients, providing immediate relief from symptoms like shortness of breath and wheezing. Administering a bronchodilator first is crucial in managing an acute asthma attack. Corticosteroids (choices B and C) are used for long-term management and take longer to have an effect. Antibiotics (choice D) are not indicated for asthma unless there is a secondary bacterial infection present. Therefore, the priority is to administer a bronchodilator for rapid relief of asthma symptoms.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. Nitroglycerin is the first-line medication for chest pain related to myocardial infarction as it helps dilate blood vessels, improving blood flow to the heart. Administering nitroglycerin promptly can help relieve chest pain and prevent further damage to the heart. Summary of other choices: B: Administer beta-blockers - Beta-blockers may be used later to stabilize the heart rate and blood pressure but are not the priority in the acute phase of MI. C: Administer oxygen and monitor - Administering oxygen is important, but nitroglycerin takes precedence in relieving chest pain and improving blood flow. D: Administer analgesics - While analgesics may help with pain relief, nitroglycerin is specifically indicated for chest pain related to MI and should be given first.

Correct Answer: D

Rationale: The correct answer is D: Administer insulin. The priority nursing action is to manage the patient's blood glucose levels when experiencing nausea and vomiting, as it may lead to diabetic ketoacidosis. Administering insulin helps stabilize blood sugar. Administering antiemetics (A and B) may provide symptomatic relief but does not address the underlying issue. Administering pain medications (C) is not the priority in this scenario.

Correct Answer: D

Rationale: Increased albuterol use suggests poor asthma control, indicating a need for education on proper management and prevention.