Which action should be performed first when assessing a hospitalized patient with shortness of breath?

Correct Answer: C

Rationale: The correct action is to obtain baseline information first, then do a complete assessment (Choice C). This is important as it allows the healthcare provider to gather initial vital signs and key information before proceeding with a thorough assessment. By obtaining baseline information first, the healthcare provider can assess the patient's current status and identify any urgent needs requiring immediate attention. This approach helps in prioritizing the assessment and subsequent interventions. Examining only the body areas related to the problem (Choice A) may lead to missing important clues to the patient's condition. Obtaining a thorough history and physical assessment from the family (Choice B) can provide valuable information but should not be the first step in assessing the patient's immediate needs. Examining the entire body to determine if the problem is linked to something else (Choice D) is not the most efficient approach as it may delay identifying and addressing the primary issue causing shortness of breath.

Correct Answer: C

Rationale: The correct answer is C: Monitor the client's blood pressure. When a client develops a fever after surgery, it could indicate various causes, including infection or inflammatory response. Monitoring blood pressure is essential to assess circulatory status, as fever can lead to increased heart rate and decreased blood pressure. Administering antibiotics (choice A) should only be done if infection is confirmed. Monitoring temperature and assessing for infection (choice B) is important but not the immediate priority. Administering fluid resuscitation (choice D) may be necessary based on the client's overall condition but should be guided by monitoring blood pressure.

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: B

Rationale: The correct answer is B: Advise the patient to sleep with the head of the bed elevated. Elevating the head of the bed helps prevent stomach acid from flowing back into the esophagus during sleep, reducing GERD symptoms. This position also promotes better digestion. Choices A, C, and D are incorrect because encouraging large meals before bedtime can worsen GERD symptoms, drinking caffeinated beverages can trigger acid reflux, and avoiding antacids can lead to inadequate symptom management.

Correct Answer: D

Rationale: The correct answer is D because it provides a thorough list of specific childhood illnesses and confirms the patient's denial of having had them. This approach ensures comprehensive documentation and accuracy. Choice A is vague and lacks specificity, potentially leading to misunderstandings. Choice B focuses on the patient's perception of their health rather than actual illnesses. Choice C mentions the patient's sister and measles, which is irrelevant to the patient's own medical history. Overall, choice D is the most accurate and relevant option for documenting the patient's childhood illnesses.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. In severe allergic reactions, such as anaphylaxis, epinephrine is the first-line treatment as it rapidly reverses life-threatening symptoms like airway constriction and low blood pressure. Antihistamines (choice B) may help with mild symptoms but are not sufficient for severe reactions. Applying a cold compress (choice C) is not effective in treating anaphylaxis. Encouraging deep breathing (choice D) is not appropriate as the client may have difficulty breathing due to airway constriction. Administering epinephrine is crucial to quickly stabilize the client's condition in a severe allergic reaction.

Correct Answer: B

Rationale: The correct answer is B: Administer fluids. Administering fluids is the priority when caring for a client receiving a blood transfusion to prevent circulatory overload. Vital signs (A) should be monitored before and after the transfusion but are not the priority. Monitoring for transfusion reactions (C) is important but comes after administering fluids. Obtaining a blood sample (D) is not a priority during a blood transfusion. Administering fluids ensures adequate hydration and prevents complications during the transfusion process.

Correct Answer: A

Rationale: Administering aspirin is the most appropriate intervention for a client experiencing a heart attack. Aspirin helps prevent blood clot formation, which is crucial in reducing further damage to the heart during a heart attack. It inhibits platelets from clumping together, improving blood flow to the heart muscle. Thrombolytics are used to dissolve existing blood clots, but aspirin is more preventive. Monitoring for arrhythmias is important but not the initial intervention. Administering morphine can be considered for pain relief but is not as crucial as administering aspirin to prevent further clot formation.

Correct Answer: B

Rationale: Correct Answer: B (Administer nonsteroidal anti-inflammatory drugs - NSAIDs) Rationale: 1. NSAIDs are commonly used for chronic pain management due to their anti-inflammatory properties. 2. NSAIDs target the underlying inflammation that often contributes to chronic pain. 3. Opioids may be reserved for severe pain due to their potential for addiction and side effects. 4. Monitoring blood pressure is important but not the primary intervention for chronic pain. 5. Acetaminophen is a mild pain reliever and may not be as effective for chronic pain compared to NSAIDs.