Correct Answer: C

Rationale: The correct action the nurse should take for a client at risk for developing DVT is to apply sequential compression devices to the client's legs. This intervention helps prevent venous stasis by promoting circulation and reducing the risk of DVT. Encouraging the client to remain on bed rest (
Choice
A) can actually increase the risk of DVT due to immobility. Massaging the client's legs every 4 hours (
Choice
B) can dislodge blood clots and is contraindicated in DVT prevention. While administering anticoagulants as prescribed (
Choice
D) is a treatment for DVT, it is not a preventive measure for a client at risk.

Correct Answer: C

Rationale: The correct answer is C: aPTT. Monitoring the activated partial thromboplastin time (aPTT) is crucial when a client is receiving heparin therapy. The aPTT reflects the clotting time and helps assess the effectiveness of heparin in preventing clot formation. Keeping the aPTT within the therapeutic range ensures that the medication is working optimally.

Choices A, B, and D are incorrect because serum potassium, platelets, and INR are not direct indicators of heparin's effectiveness or therapeutic range.

Correct Answer: D

Rationale: The correct answer is D because viewing the newborn's actions as uncooperative indicates a lack of bonding, which requires intervention.

Choices A, B, and C all involve appropriate and caring actions by the client towards the newborn. Holding the newborn in an en face position promotes bonding, involving the father in caring for the newborn is beneficial for family involvement, and requesting rest by asking the nurse to take the newborn to the nursery is a responsible action to ensure both the client and the newborn get adequate rest.

Correct Answer: B

Rationale: Administering oxygen is crucial in managing a patient with respiratory distress as it helps improve oxygenation and alleviate breathing difficulties. While administering bronchodilators may be beneficial in certain respiratory conditions like asthma or COPD, in a patient with respiratory distress, ensuring adequate oxygen supply takes precedence. Checking oxygen saturation is important, but the immediate intervention to address respiratory distress is providing supplemental oxygen. Repositioning the patient may be helpful in optimizing ventilation but is not the primary intervention in managing acute respiratory distress.

Correct Answer: A

Rationale: Administering oxygen is the best nursing action for a patient experiencing shortness of breath as it helps alleviate the symptoms and improve oxygenation. Providing oxygen addresses the primary issue of inadequate oxygen levels in the body, which can be a life-threatening situation. Administering bronchodilators (choice
B) may be appropriate for specific respiratory conditions like asthma but is not the initial intervention for all causes of shortness of breath. Repositioning the patient (choice
C) can sometimes help improve breathing, but in a patient experiencing significant shortness of breath, immediate oxygen therapy is crucial. Providing IV fluids (choice
D) is not indicated as the first-line intervention for shortness of breath unless there is a specific underlying cause such as dehydration.