health assessment test bank jarvis

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. This is the most important nursing intervention for a client with severe dehydration because IV fluids provide rapid rehydration and help restore electrolyte balance efficiently. Monitoring vital signs (choice B) is important but not as crucial as providing immediate fluid replacement. Providing oral rehydration (choice C) may not be effective for severe dehydration as the client may have difficulty absorbing fluids orally. Administering oxygen (choice D) is not directly related to treating dehydration, so it is not the most important intervention in this scenario.

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: 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: A

Rationale: Step-by-step rationale for why choice A is correct: 1. Monitoring blood glucose levels regularly allows for timely adjustments in treatment. 2. It helps in preventing hypoglycemia or hyperglycemia complications. 3. Enables the patient to understand how their lifestyle choices impact their blood sugar levels. 4. Empowers the patient to make informed decisions regarding their diabetes management. Summary of why the other choices are incorrect: B: Limiting physical activity can lead to complications like obesity and decreased insulin sensitivity. C: Diet should focus on balanced nutrition, not just low-fat or high-protein, to manage diabetes effectively. D: Taking insulin regardless of blood sugar levels can result in hypoglycemia or poor blood sugar control.

Correct Answer: C

Rationale: The correct immediate intervention for a hypoglycemic client is to provide 4-6 ounces of fruit juice with sugar. This is because the client needs a quick source of glucose to raise their blood sugar levels rapidly. Fruit juice with sugar is easily absorbed, providing a fast-acting solution to hypoglycemia. Commercially prepared glucose tablets may take longer to be absorbed than fruit juice. Hard candies and honey may not contain enough sugar to raise blood sugar levels quickly compared to fruit juice. Therefore, fruit juice with sugar is the most effective option for immediate intervention in hypoglycemic clients.