health assessment test bank jarvis

Correct Answer: A

Rationale: The correct answer is A: Hyperkalemia. In chronic kidney disease, the kidneys are unable to effectively excrete potassium, leading to elevated levels in the blood. This can result in life-threatening cardiac arrhythmias. Monitoring for hyperkalemia is crucial in managing patients with kidney disease. Other choices are incorrect because: B: Hypoglycemia is not typically associated with chronic kidney disease. C: Hypotension may occur in kidney disease but is not directly related to decreased renal function. D: Hypercalcemia is not a common complication of decreased renal function; in fact, kidney disease can lead to low levels of calcium.

Correct Answer: A

Rationale: The correct answer is A: Secure the airway. This is the highest priority for a nurse treating a client with a stab wound to the chest because airway management is crucial for ensuring the client can breathe effectively. If the airway is compromised, the client may not be able to oxygenate properly, leading to serious complications or even death. Administering oxygen (choice B) can help with oxygenation but is not as critical as ensuring the airway is clear. Turning the client (choice C) or applying an abdominal binder (choice D) are not appropriate actions for a stab wound to the chest and would not address the immediate life-threatening issue of airway compromise.

Correct Answer: C

Rationale: The correct answer is C: "Never did too good in school." This statement should be explored further during an interview because it can provide insights into the patient's educational background, potential learning difficulties, or past experiences that may impact their health literacy or understanding of medical information. Understanding the patient's educational history can help the nurse tailor communication and education strategies effectively. A: "Sleeps like a baby" is not as critical for further exploration as it pertains to the patient's sleep quality. B: "Has no health problems" is important information but does not require immediate further exploration. D: "Is currently not taking any medication" is important for medication reconciliation but does not warrant immediate further exploration in this context.

Correct Answer: B

Rationale: The correct answer is B: Monitor for arrhythmias. This is because in a client showing signs of shock after surgery, the priority is to assess for any cardiac complications such as arrhythmias, which can be life-threatening. Monitoring for arrhythmias allows prompt identification and intervention. Administering a blood transfusion (A) may be necessary in some cases of shock but is not the first intervention. Administering oxygen (C) may also be necessary, but addressing cardiac complications takes precedence. Encouraging deep breathing (D) is not a priority in managing shock-related complications.

Correct Answer: D

Rationale: The correct answer is D: Administer nitroglycerin. In acute pancreatitis, pancreatic inflammation can lead to pancreatic ischemia due to decreased blood flow. Nitroglycerin helps to dilate blood vessels and improve blood flow to the pancreas, reducing ischemia and potentially preventing further damage. Pain relief (choice A) may be necessary but does not address the underlying issue of ischemia. Administering fluids (choices B and C) is important but not the most critical intervention in this case. Administering nitroglycerin is the most crucial because it targets the root cause of pancreatic ischemia in acute pancreatitis.