A client with a history of hypertension is admitted with acute renal failure. Which assessment finding requires immediate intervention?

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Question 1 of 5

A client with a history of hypertension is admitted with acute renal failure. Which assessment finding requires immediate intervention?

Correct Answer: B

Rationale: Urine output of 50 mL in 4 hours indicates oliguria, which can be a sign of worsening renal function and requires immediate intervention. In acute renal failure, maintaining adequate urine output is crucial to prevent further kidney damage and manage fluid balance. A high blood pressure reading (Option A) is concerning but may not require immediate intervention in this scenario as it could be due to the history of hypertension. A heart rate of 100 beats per minute (Option C) is slightly elevated but may not be the most critical finding at this moment. Nausea and vomiting (Option D) are important to assess but are not as urgent as addressing oliguria in a client with acute renal failure.

Question 2 of 5

The healthcare provider is assessing a client with a suspected stroke. Which finding requires immediate intervention?

Correct Answer: C

Rationale: Difficulty speaking is a classic symptom of stroke, suggesting a potential blockage of blood flow to the brain. Prompt intervention is crucial to minimize brain damage. Elevated blood pressure (Choice A) may need management but is not the most urgent concern in this scenario. A blood glucose level of 180 mg/dL (Choice B) is slightly elevated but does not require immediate intervention for a suspected stroke. A temperature of 99.8°F (37.7°C) (Choice D) is within normal range and not a critical finding in this context.

Question 3 of 5

The healthcare professional is developing a community health program to address the high rates of childhood asthma in a neighborhood. Which intervention should the healthcare professional prioritize?

Correct Answer: A

Rationale: The healthcare professional should prioritize conducting home visits to identify asthma triggers as it is crucial for reducing asthma attacks in children. By identifying triggers in the home environment, interventions can be implemented to create a safer living space for children with asthma. Distributing asthma education materials at schools may be helpful, but addressing triggers at the source is more direct and impactful. Holding workshops on asthma management for parents is valuable, but identifying triggers should come first to prevent asthma exacerbations. Partnering with local healthcare providers to offer free asthma screenings focuses on detection rather than prevention through trigger identification.

Question 4 of 5

During a health assessment for a family with a history of cardiovascular disease, which family member should be prioritized for further evaluation and intervention?

Correct Answer: A

Rationale: The 45-year-old father who smokes and has high cholesterol should be prioritized for further evaluation and intervention. He has multiple risk factors for cardiovascular disease, including smoking and high cholesterol, which significantly increase his risk. Addressing these modifiable risk factors is crucial in preventing cardiovascular events. The daughter (Choice B) and mother (Choice C) also have risk factors, but the father's combination of smoking and high cholesterol places him at higher immediate risk, demanding priority intervention. The 12-year-old son (Choice D) with a normal weight and an active lifestyle has a lower risk profile and does not require immediate intervention compared to the father.

Question 5 of 5

A client who is receiving intravenous heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. Which action should the nurse take?

Correct Answer: D

Rationale: An aPTT of 90 seconds is significantly elevated, indicating a high risk of bleeding due to excessive anticoagulation. In this case, the heparin infusion should be stopped immediately to prevent further anticoagulation and an increased bleeding risk. Notifying the healthcare provider is essential to discuss alternative anticoagulation strategies or interventions. Continuing heparin therapy without action could lead to severe bleeding complications. Decreasing or increasing the heparin infusion rate would exacerbate the risk of bleeding, making options A, B, and C incorrect.

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