test bank for health assessment

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: 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: A

Rationale: The proper hand position for chest percussion is to cup the hands, creating a hollow space to allow for effective transmission of percussion vibrations. Cupping the hands helps to produce the desired percussion sound and ensures proper force distribution. Using the side of the hands (B) may not provide enough surface area for effective percussion. Flattening the hands (C) may not generate the desired percussive effect, and spreading the fingers of both hands (D) can result in uneven force application. Therefore, cupping the hands is the most appropriate hand position for chest percussion.

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.