What is the priority nursing intervention for a client experiencing chest pain and a history of heart disease?

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. This is the priority intervention because nitroglycerin helps dilate blood vessels, reducing chest pain in clients with heart disease. It improves blood flow to the heart, relieving ischemia. Morphine (B) can mask symptoms and should be used if pain persists after nitroglycerin. Beta blockers (C) are beneficial in chronic management but not for immediate relief. Aspirin (D) helps prevent clot formation but is not the priority in acute chest pain.

Correct Answer: C

Rationale: The most important goal for a nurse when implementing care for a patient with a chronic illness is to prevent future complications (Choice C). This is because chronic illnesses are long-term conditions that require ongoing management to minimize the risk of complications and improve the patient's quality of life. By preventing future complications, the nurse helps maintain the patient's health and prevents the progression of the disease. Providing emotional support (Choice D) is important but not the most crucial goal in this context. While reducing symptoms (Choice B) is important, preventing future complications takes precedence as it addresses the underlying cause of the illness. Curing the disease (Choice A) may not always be feasible for chronic illnesses, making prevention of complications a more realistic and essential goal.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Sodium restriction helps prevent fluid retention and high blood pressure in CKD. 2. Limiting sodium intake is crucial in managing CKD-related complications. 3. Excess sodium can worsen fluid retention and strain the kidneys. 4. Proper understanding of sodium limitation shows patient's grasp of CKD management. Incorrect Choices: B. Increasing fluid intake can worsen fluid retention in CKD patients. C. Excessive protein intake can burden the kidneys in CKD. D. High potassium levels in CKD can lead to dangerous heart rhythm abnormalities.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. When a client is experiencing respiratory distress, the priority intervention is to open up the airways to improve breathing. Bronchodilators help relax and widen the airways, making it easier for the client to breathe. This intervention addresses the immediate need for improved respiratory function. Administering corticosteroids (choices B and C) may be beneficial in some cases but is not the priority in acute respiratory distress. Monitoring respiratory rate (choice D) is important but does not directly address the underlying issue of airway constriction in respiratory distress.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants are crucial in treating DVT as they prevent blood clots from getting larger and stop new clots from forming. They help reduce the risk of complications like pulmonary embolism. Administering analgesics (B) may help with pain but does not address the root cause. Diuretics (C) are used to treat conditions like fluid retention, not DVT. Applying a warm compress (D) can actually worsen DVT by promoting blood flow. Anticoagulants are the gold standard treatment for DVT.

Correct Answer: B

Rationale: The correct answer is B: To monitor the amount of airway obstruction. A peak flow meter is used to measure how well the patient can exhale air from the lungs, indicating the degree of airway obstruction in conditions like asthma. By monitoring peak flow readings, the nurse can assess the severity of the patient's asthma and adjust treatment accordingly. Choices A, C, and D are incorrect: A: To measure the amount of oxygen in the blood - This is the function of a pulse oximeter, not a peak flow meter. C: To measure the frequency of inhaler use - This is not the primary purpose of a peak flow meter, which is specifically used to monitor airway obstruction. D: To track blood glucose levels - This is the function of a glucometer, not a peak flow meter used for asthma management.

Correct Answer: A

Rationale: Step 1: Cirrhosis can impair the liver's ability to store glycogen and produce glucose. Step 2: Liver dysfunction can lead to hypoglycemia due to decreased glycogen stores and gluconeogenesis. Step 3: Monitoring for hypoglycemia is crucial as it can result in serious complications. Step 4: Hyperglycemia (B) is less likely in cirrhosis as the liver's ability to regulate blood sugar is impaired. Step 5: Hypokalemia (C) and hyperkalemia (D) are less directly related to cirrhosis and are not the primary concerns in this case.

Correct Answer: A

Rationale: The correct answer is A: Administer antiemetics. This intervention helps to reduce nausea and vomiting by blocking the neurotransmitters responsible for triggering these symptoms. Administering antiemetics is the most direct and effective approach to address severe nausea and vomiting post-surgery. Choice B (Placing the client in a supine position) is incorrect because it does not directly address the underlying cause of nausea and vomiting. Choice C (Providing hydration) is important but may not alleviate the symptoms of severe nausea and vomiting. Choice D (Monitoring bowel sounds) is important for assessing gastrointestinal motility but does not directly address the immediate symptoms of nausea and vomiting.

Correct Answer: A

Rationale: The correct answer is A because it focuses on prioritizing the assessment by first addressing the immediate problem of shortness of breath. By examining only the body areas related to the current issue, the nurse can quickly gather essential information to manage the patient's respiratory distress effectively. Once the critical issue is stabilized, a complete assessment can be conducted to identify any underlying problems or potential complications. This approach ensures that the nurse addresses the most urgent needs first before proceeding to a comprehensive assessment. Choice B is incorrect because it suggests only examining body areas directly related to the hospitalization problem, which may overlook other critical issues contributing to the shortness of breath. Choice C is incorrect as shortness of breath is not a normal finding and should not be dismissed without further evaluation. Choice D is incorrect as examining the entire body without focusing on the immediate issue may delay appropriate interventions for the patient's respiratory distress.