health assessment test bank jarvis

Correct Answer: B

Rationale: The correct answer is B: Urine output monitoring. This method is the best for assessing fluid balance in a client with kidney disease because the kidneys play a key role in regulating fluid balance by controlling urine production. Monitoring urine output provides direct insight into the body's fluid status and kidney function. Daily weight measurements (A) can be influenced by factors other than fluid balance. Electrolyte panel monitoring (C) assesses electrolyte levels, not fluid balance specifically. Monitoring vital signs (D) can give clues to fluid imbalance but is not as direct or specific as urine output monitoring.

Correct Answer: A

Rationale: The correct answer is A: Increasing physical activity and reducing salt intake. Firstly, increasing physical activity helps lower blood pressure by improving heart health and circulation. Secondly, reducing salt intake helps decrease fluid retention and lower blood pressure. The other choices are incorrect because B: Increasing alcohol consumption can raise blood pressure, C: Decreasing physical activity is counterproductive, and D: Increasing sodium intake can lead to higher blood pressure due to fluid retention. Prioritizing physical activity and reducing salt intake are evidence-based lifestyle changes to manage hypertension effectively.

Correct Answer: A

Rationale: The correct answer is A because it helps differentiate between orthopnea (difficulty breathing when lying down) and paroxysmal nocturnal dyspnea (sudden awakening due to difficulty breathing). By asking about worsening symptoms when lying down, the nurse can assess if the patient has orthopnea, a classic symptom of heart failure. Choices B, C, and D are incorrect because they do not specifically target the nighttime breathing difficulty associated with heart failure.

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. This is the best nursing action for a client with a wound infection because antibiotics are necessary to treat the infection at its source, targeting the bacteria causing the infection. Antibiotics help prevent the infection from spreading and promote healing. Explanation of why other choices are incorrect: B: Applying a sterile dressing is important for wound care but does not address the underlying infection. C: Monitoring blood pressure is important for overall patient assessment but does not directly treat the wound infection. D: Placing the client in a sitting position is not relevant to treating a wound infection.

Correct Answer: A

Rationale: Administering oxygen is the most important action for a client with respiratory distress because it helps improve oxygen levels in the blood and supports breathing. Oxygen therapy can prevent hypoxia and reduce respiratory workload. Corticosteroids, bronchodilators, and analgesics may be beneficial in specific situations, but they are not the primary intervention for respiratory distress. Corticosteroids reduce inflammation, bronchodilators help open airways, and analgesics provide pain relief but do not directly address the underlying issue of inadequate oxygenation. Administering oxygen should always be the first priority in managing respiratory distress.