health assessment test bank

Correct Answer: C

Rationale: Correct Answer: C - Administer IV fluids Rationale: 1. Assess patient's fluid status and hydration level. 2. IV fluids help maintain adequate hydration during hemodialysis. 3. Prevents hypotension and ensures stable blood pressure during the procedure. 4. Improves overall hemodialysis efficiency and patient safety. Summary: A: Checking patency is important, but not the primary intervention for hemodialysis. B: Monitoring for bleeding is crucial but not specific to AVF assessment. D: Applying an airtight dressing is not necessary for AVF assessment.

Correct Answer: A

Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial for a patient with diabetes and peripheral neuropathy to prevent complications like diabetic foot ulcers. Daily foot inspections can help detect any injuries or changes early to prevent infection or further damage. It is important to prioritize this over other choices because early intervention can prevent serious consequences. Engaging in weight-bearing exercise (choice B) can be beneficial but may not be the priority in this case. Increasing protein intake (choice C) is not directly related to foot care. Using tight-fitting shoes (choice D) can lead to pressure ulcers and should be avoided.

Correct Answer: A

Rationale: The correct first action is A: Apply pressure and elevate the limb. This is because applying pressure helps control bleeding and elevating the limb reduces blood flow to the area, minimizing further blood loss. This immediate intervention is crucial in managing the traumatic amputation and preventing complications. Summary of why other choices are incorrect: B: Stopping bleeding and controlling shock can be important but not the first action. C: Placing the client in a Trendelenburg position (feet elevated higher than the head) is contraindicated in cases of traumatic amputation as it can increase bleeding. D: Placing the client in a sitting position is not appropriate as it can worsen bleeding and lead to further complications.

Correct Answer: A

Rationale: The priority nursing intervention for a client with asthma experiencing wheezing is to administer oxygen. Wheezing indicates airway constriction and decreased oxygenation, making oxygen crucial for adequate tissue perfusion. Administering oxygen helps improve oxygen levels, alleviate respiratory distress, and prevent hypoxemia. Applying a bronchodilator (Choice B) may be beneficial after oxygen is administered. Applying a cold compress (Choice C) is not indicated for asthma exacerbations, and encouraging deep breathing (Choice D) may worsen respiratory distress in a client with wheezing. In summary, administering oxygen is the priority intervention to address the immediate respiratory needs of the client with asthma and wheezing.

Correct Answer: B

Rationale: The correct answer is B: Monitoring serum albumin levels. This is because serum albumin is a protein synthesized by the liver that reflects long-term protein intake and overall nutritional status. Low levels indicate malnutrition or inflammation. Obtaining a dietary history (choice A) is important but may not always reflect the actual nutritional status. Monitoring weight (choice C) is helpful but may not provide a comprehensive view of the client's nutritional status. Providing a meal plan (choice D) is a proactive approach but does not directly assess the client's current nutritional status.