test bank for health assessment

Correct Answer: A

Rationale: Step 1: Stop the transfusion - Febrile reaction can indicate a transfusion reaction, so stopping the transfusion is crucial. Step 2: Administer antipyretics - To reduce fever and prevent further complications. Step 3: Assess for other signs of transfusion reaction - Such as chills, rash, or hypotension. Summary: Option A is correct as it addresses the immediate need to stop the transfusion and manage the fever. Options B, C, and D do not prioritize stopping the transfusion, which is crucial in this scenario.

Correct Answer: B

Rationale: Correct Answer: B - Administer oxygen Rationale: 1. Oxygen therapy is crucial in managing COPD exacerbation to improve oxygen saturation levels. 2. Adequate oxygenation is essential to prevent further respiratory distress and potential complications. 3. Oxygen therapy helps alleviate symptoms like shortness of breath and fatigue, improving overall comfort. 4. Monitoring oxygen saturation levels guides the effectiveness of treatment and ensures appropriate oxygen delivery. Summary: - Administering corticosteroids (A) may help reduce inflammation in COPD exacerbation but does not address the immediate need for oxygen. - Monitoring respiratory rate (C) is important but prioritizing oxygen administration is more critical for immediate respiratory support. - Administering diuretics (D) may be indicated in certain cases of COPD exacerbation with fluid retention but is not the priority over oxygen therapy.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. In the case of shock, the first priority is to restore circulating volume to improve tissue perfusion. IV fluids help increase blood volume and improve oxygen delivery to vital organs, addressing the underlying cause of shock. Choice B (Administer oxygen) can be important but is not the first priority. Choice C (Place the client in a supine position) may worsen certain types of shock. Choice D (Monitor blood pressure) is important but not the first action needed to address shock. Administering IV fluids promptly can stabilize the client's condition and prevent further deterioration.

Correct Answer: A

Rationale: The correct answer is A: Assess airway. In caring for a client with a traumatic head injury, the first priority is to ensure there is a clear airway to maintain oxygenation and ventilation, which is crucial for brain function. If the airway is compromised, it can lead to hypoxia and further brain damage. Providing pain relief (B) is important but not the immediate priority. Monitoring intracranial pressure (C) is essential but comes after ensuring a patent airway. Maintaining a quiet environment (D) can help reduce stimulation, but it is not as critical as assessing the airway for immediate intervention.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. This is the most important intervention for a client with an obstructed airway because it helps to ensure that the patient is receiving adequate oxygen supply to prevent hypoxia. Oxygen therapy can help maintain oxygen saturation levels and support proper gas exchange in the lungs. Monitoring respiratory rate (B) is important but not as critical as ensuring oxygen supply. Administering morphine (C) is contraindicated as it can depress respiratory function further. Administering fluids (D) is not the priority in managing an obstructed airway.