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1. A 55-year-old patient with a history of diabetes presents to the
emergency department with chest pain, shortness of breath, and
diaphoresis. The nurse suspects the patient is experiencing a myocardial
infarction. What action should the nurse take first?
A. Administer sublingual nitroglycerin
B. Order an EKG
C. Obtain a blood glucose level
D. Assess the patient's pain level and location
Answer: B. Order an EKG
Rationale: An EKG is the priority in patients suspected of having a
myocardial infarction to quickly assess for ST-segment elevation, which
helps determine the need for immediate interventions.
2. A 30-year-old female patient with a history of asthma is admitted for
shortness of breath and wheezing. The nurse notes the patient's respiratory
rate is 28 breaths/min, with the use of accessory muscles. Which action
should the nurse prioritize?
A. Administer a nebulizer treatment
B. Administer oxygen via nasal cannula
C. Obtain a chest X-ray
D. Administer intravenous steroids
Answer: A. Administer a nebulizer treatment
Rationale: In a patient with respiratory distress, the priority is to relieve
bronchospasm and improve oxygenation by administering a
bronchodilator such as albuterol via a nebulizer.
3. An 80-year-old patient with a history of heart failure presents with fluid
overload, crackles in the lungs, and edema in the lower extremities. Which
intervention should the nurse implement first?
A. Administer intravenous furosemide
B. Elevate the patient's legs
C. Assess daily weights and fluid intake
D. Restrict sodium intake in the diet
Answer: A. Administer intravenous furosemide
Rationale: In patients with acute decompensated heart failure, the priority
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