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: A

Rationale: The correct answer is A: Administer IV fluids. The priority nursing action for a client with severe dehydration is to restore fluid volume to maintain vital organ function. Administering IV fluids is crucial in rapidly replenishing lost fluids and electrolytes. Corticosteroids (choice B) are not indicated for dehydration. Re-administering IV fluids (choice C) is redundant. Administering analgesics (choice D) is not a priority in the management of severe dehydration.

Correct Answer: A

Rationale: The correct answer is A: Cleanse and dress the wound. This intervention is essential as it helps prevent infection, promotes healing, and maintains a moist wound environment. Cleansing removes debris and bacteria, while dressing protects the wound from external contaminants. Administering antibiotics (choice B) is not the initial intervention for an open wound. Placing a sterile dressing (choice C) is important, but cleansing the wound first is crucial. Ensuring wound care is sterile (choice D) is important, but the primary focus should be on cleansing and dressing the wound.

Correct Answer: A

Rationale: The correct answer is A (Broccoli, oranges, dark greens) because these foods are high in soluble fiber, antioxidants, and plant sterols which are known to help lower cholesterol levels. Broccoli contains fiber that binds to cholesterol in the gut, oranges are rich in vitamin C and fiber, and dark greens like spinach and kale are packed with antioxidants and fiber. Option B (Fiber-rich foods) is partially correct as fiber can help reduce cholesterol levels, but it is not as specific as the foods mentioned in option A. Option C (Increase intake of omega-3 fatty acids) is not directly related to lowering cholesterol, although omega-3s have other health benefits. Option D (Eliminate fat-rich foods) is not ideal as not all fats are bad for cholesterol, and some healthy fats like those found in avocados and nuts can actually improve cholesterol levels.

Correct Answer: B

Rationale: The correct answer is B: Administer thrombolytics. Thrombolytics help dissolve blood clots, which may be causing the stroke. Administering thrombolytics promptly can improve blood flow to the brain, potentially reducing the severity of the stroke and its effects, including difficulty speaking. Calling for help (A) is important, but administering thrombolytics should be a priority. Performing a CT scan (C) may help confirm the type of stroke but may delay immediate treatment. Administering bronchodilators (D) is not indicated for difficulty speaking related to stroke.