test bank for health assessment

Correct Answer: B

Rationale: Rationale: 1. pH within normal range (7.35-7.45) indicates homeostasis. 2. PO2 (normal 75-100 mmHg) and PCO2 (normal 35-45 mmHg) are slightly deviated but not clinically significant. 3. HCO3 within normal range (22-26 mEq/L) further supports overall balance. Summary: A: Incorrect - HCO3 level is within normal range, ruling out metabolic alkalosis. C: Incorrect - PCO2 is within normal range, ruling out respiratory acidosis. D: Incorrect - PCO2 is slightly low but not significantly, ruling out respiratory alkalosis. Overall, the ABG values indicate the body is in homeostasis.

Correct Answer: B

Rationale: The correct action for a client with DVT in the leg is to apply compression and elevate the leg (Choice B). Compression helps prevent blood clots from moving and causing further complications. Elevating the leg reduces swelling and improves blood flow. Choice A is incorrect because applying heat can actually worsen DVT by promoting inflammation and increasing blood flow. Choice C is incorrect as massage can dislodge blood clots and lead to serious complications like pulmonary embolism. Choice D is incorrect as massaging the leg can be dangerous in DVT as mentioned before.

Correct Answer: A

Rationale: The nurse should first administer aspirin to a client with chest pain as it helps prevent blood clot formation during a possible heart attack. Aspirin inhibits platelet aggregation, reducing the risk of further blockage in the coronary arteries. Administering aspirin promptly can improve the client's outcomes. Performing an ECG, monitoring vital signs, or providing a meal plan are important but should come after administering aspirin in the initial management of chest pain to prioritize the client's safety and well-being.

Correct Answer: B

Rationale: The correct answer is B: Tenderness, warmth, and swelling at the site. Post-operative wound infection often presents with localized tenderness, warmth, and swelling due to inflammation and immune response. Redness, heat, and purulent drainage (choice A) can also indicate infection but are not specific to wound infections. Excessive swelling and redness (choice C) may be present in inflammatory responses but do not specifically point to an infection. Fever, chills, and nausea (choice D) can be systemic signs of infection but are not specific to wound infections. Tenderness, warmth, and swelling are more indicative of a localized wound infection.

Correct Answer: A

Rationale: The correct answer is A: Administer pain relief. This is the priority action because managing pain is crucial in providing comfort and reducing distress for the client with a severe burn. Pain relief helps in improving the client's overall well-being and promotes better recovery. Administering corticosteroids (Choice B) is not the priority as pain relief takes precedence. Monitoring for infection (Choice C) is important but not the immediate priority. Applying dressings (Choice D) is also important but should come after administering pain relief.