jarvis health assessment test bank

Correct Answer: A

Rationale: The correct answer is A: Breath sounds and oxygen saturation. In COPD, monitoring respiratory status is crucial due to impaired gas exchange. Assessing breath sounds helps identify any adventitious sounds like wheezing or crackles, indicating respiratory distress. Oxygen saturation reflects oxygenation status, vital for patients with COPD prone to hypoxemia. Nutritional intake and weight (B), bowel sounds and abdominal girth (C), and urine output and skin integrity (D) are important but secondary assessments in this case. Nutritional status and weight are important for overall health, bowel sounds and abdominal girth are related to gastrointestinal function, and urine output and skin integrity are indicators of hydration and overall skin health, respectively. However, in a patient with COPD, the priority is ensuring adequate oxygenation and respiratory function.

Correct Answer: A

Rationale: The correct answer is A: Shortness of breath and weight gain. In chronic heart failure, fluid overload can lead to pulmonary congestion, causing shortness of breath. Weight gain is also a key sign of fluid retention. Increased urine output and hypotension (choice B) are more indicative of dehydration. Fatigue and dizziness (choice C) can be nonspecific symptoms and not directly related to fluid overload. Dry mouth and thirst (choice D) are symptoms of dehydration rather than fluid overload in chronic heart failure. Monitoring for shortness of breath and weight gain allows for early detection and intervention in managing fluid overload in patients with chronic heart failure.

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: D

Rationale: Correct Answer: D Rationale: 1. Washing hands before and after cord care is a standard hygiene practice to prevent infection. 2. Options A and B are incorrect as alcohol and covering the cord can lead to complications. 3. Option C suggests recognizing concerning changes in the cord, indicating good understanding. 4. Thus, option D is correct as it is a crucial step in cord care and does not indicate a need for further teaching.

Correct Answer: B

Rationale: The correct answer is B: a set of rules. Novice nurses rely on established guidelines and protocols to make decisions as they lack the experience to rely solely on intuition or journal articles. Rules provide structure and consistency in decision-making, reducing the margin of error. Intuition (choice A) may not be reliable without prior experience. Journal articles (choice C) can be overwhelming and may not directly apply to the specific situation. Advice from supervisors (choice D) can be helpful but may not always be readily available, and it's important for novice nurses to develop their own decision-making skills.