health assessment test bank

Correct Answer: B

Rationale: The correct answer is B: Monitor INR levels. INR (International Normalized Ratio) is a crucial parameter to monitor for clients on anticoagulant therapy, as it measures the effectiveness of the medication in preventing blood clots. By monitoring INR levels, the nurse can ensure the client is within the therapeutic range to prevent both bleeding and clotting complications. Choice A (Monitor platelet count) is incorrect because anticoagulant therapy does not directly affect platelet count, and monitoring platelets is more relevant for clients on antiplatelet therapy. Choice C (Monitor bleeding) is partially correct, but focusing solely on monitoring bleeding may not provide a comprehensive assessment of the client's response to anticoagulant therapy. Choice D (Monitor renal function) is incorrect as anticoagulant therapy primarily affects coagulation factors and not renal function. Renal function monitoring may be necessary for certain medications but is not a primary consideration for anticoagulant therapy.

Correct Answer: C

Rationale: The correct answer is C: sodium and chloride. In the extracellular fluid, sodium and chloride are the major electrolytes due to their roles in maintaining fluid balance, nerve function, and muscle contraction. Potassium and phosphate (choice B) are primarily found in intracellular fluid, while potassium and chloride (choice A) are not the major electrolytes in extracellular fluid. Similarly, sodium and phosphate (choice D) are not major extracellular electrolytes. Thus, choice C is the correct answer based on the significant presence and functions of sodium and chloride in the extracellular fluid.

Correct Answer: D

Rationale: The correct answer is D, administering antiepileptic medications. This is because during an active seizure, the priority is to stop the seizure activity. Antiepileptic medications are specifically designed to prevent or reduce the frequency and intensity of seizures. Placing the client on their side and protecting their head (choice A) is important for safety but does not address stopping the seizure. Loosening clothing and ensuring safety (choice B) is also important but does not directly address the seizure itself. Monitoring airway and giving oxygen (choice C) is crucial but does not actively stop the seizure. Therefore, administering antiepileptic medications is the most appropriate intervention to address the root cause of the seizure.

Correct Answer: B

Rationale: Step 1: The nurse should prioritize collecting data based on the client's acuity to address immediate needs and ensure patient safety. Step 2: Acuity determines the urgency and intensity of care required, guiding the assessment focus. Step 3: Time available or client cooperation may influence the depth of assessment but do not dictate the data collected. Step 4: The onset of symptoms is important for history-taking but not the primary factor in determining assessment data.

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating wound infections as they target and eliminate the infection-causing bacteria, preventing the infection from spreading and promoting healing. Applying a cold compress (choice B) or heat (choice C) may provide temporary relief but do not address the underlying infection. Administering IV fluids (choice D) may be necessary for hydration, but it does not directly treat the infection. Antibiotics directly target the infection, making it the most important intervention for a client with a wound infection.