test bank for health assessment

Correct Answer: A

Rationale: The correct answer is A: Monitor aPTT levels. This is crucial in intravenous heparin therapy to ensure the therapeutic range is maintained for anticoagulation without causing bleeding. Monitoring aPTT helps adjust heparin dosage to prevent clot formation or excessive bleeding. B: Monitoring for bleeding is important but not the most important action compared to monitoring aPTT levels for appropriate dosing. C: Checking platelet count is important for some anticoagulants like heparin, but aPTT monitoring is more directly related to heparin's anticoagulant effect. D: Administering a heparin antidote (protamine sulfate) is necessary in case of heparin overdose or in emergency situations but is not the primary action in routine care.

Correct Answer: A

Rationale: The correct answer is A: Monitor aPTT levels. This is crucial in intravenous heparin therapy to ensure the therapeutic range is maintained for anticoagulation without causing bleeding. Monitoring aPTT helps adjust heparin dosage to prevent clot formation or excessive bleeding. B: Monitoring for bleeding is important but not the most important action compared to monitoring aPTT levels for appropriate dosing. C: Checking platelet count is important for some anticoagulants like heparin, but aPTT monitoring is more directly related to heparin's anticoagulant effect. D: Administering a heparin antidote (protamine sulfate) is necessary in case of heparin overdose or in emergency situations but is not the primary action in routine care.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis as it helps to quickly reverse severe symptoms by constricting blood vessels and opening airways. Administering corticosteroids (B) is not the immediate priority. Placing the client on their side (C) is important to prevent aspiration but does not address the anaphylactic reaction. Monitoring blood pressure (D) is essential but administering epinephrine takes precedence in managing anaphylaxis.

Correct Answer: B

Rationale: The correct answer is B: Purchase absorbent undergarments. For stress incontinence, which is caused by weakened pelvic floor muscles, absorbent undergarments can help manage symptoms. Kegel exercises (choice A) strengthen pelvic floor muscles but may not provide immediate relief. Constipation (choice C) can exacerbate incontinence but is not the primary intervention. Surgical treatments (choice D) are not typically recommended as a first-line intervention for stress incontinence.

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.