What is the most important action when caring for a client on intravenous heparin?

Correct Answer: A

Rationale: The correct answer is A: Monitor aPTT levels. This is crucial in intravenous heparin therapy to ensure the therapeutic range is maintained for anticoagulation without causing bleeding. Monitoring aPTT helps adjust heparin dosage to prevent clot formation or excessive bleeding. B: Monitoring for bleeding is important but not the most important action compared to monitoring aPTT levels for appropriate dosing. C: Checking platelet count is important for some anticoagulants like heparin, but aPTT monitoring is more directly related to heparin's anticoagulant effect. D: Administering a heparin antidote (protamine sulfate) is necessary in case of heparin overdose or in emergency situations but is not the primary action in routine care.

Correct Answer: A

Rationale: Step 1: Stop the transfusion - Febrile reaction can indicate a transfusion reaction, so stopping the transfusion is crucial. Step 2: Administer antipyretics - To reduce fever and prevent further complications. Step 3: Assess for other signs of transfusion reaction - Such as chills, rash, or hypotension. Summary: Option A is correct as it addresses the immediate need to stop the transfusion and manage the fever. Options B, C, and D do not prioritize stopping the transfusion, which is crucial in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In hypovolemic shock, the body lacks adequate circulating blood volume leading to decreased tissue perfusion and oxygen delivery. Administering oxygen helps increase oxygen saturation levels and improve tissue oxygenation. This is the priority nursing action to ensure the client's vital organs receive sufficient oxygen. Administering pain relief (B) may be necessary but is not the priority in hypovolemic shock. Administering beta blockers (C) can further decrease blood pressure and worsen the condition. Monitoring for bleeding (D) is important, but administering oxygen takes precedence to address the immediate oxygenation needs of the client.

Correct Answer: C

Rationale: Rationale: Choice C, apply ice, is the correct answer as the first intervention for a client at risk for dehydration. Applying ice helps to lower the body temperature, which can reduce sweating and fluid loss. This intervention is crucial in preventing further dehydration. Administering IV fluids (Choice A) may be necessary in severe dehydration cases, but it is not the first intervention. Administering oxygen (Choice B) is not directly related to dehydration. Elevating the leg (Choice D) is not effective in addressing dehydration. In summary, applying ice is the most appropriate initial intervention to prevent dehydration by reducing body temperature and fluid loss.

Correct Answer: A

Rationale: The correct answer is A: coma. High ammonia levels can lead to hepatic encephalopathy, causing impaired brain function and potentially leading to coma. Edema (B) is typically associated with fluid retention, not high ammonia levels. Hypoxia (C) is a condition of low oxygen levels, not directly related to high ammonia levels. Polyuria (D) is excessive urination, which is not a common sign of high ammonia levels.

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: D

Rationale: A focused assessment is more in-depth on specific issues, providing detailed information on a particular problem or concern. This allows for targeted interventions and treatment strategies. In contrast, a comprehensive assessment covers the body head to toe and involves all body systems, which may not be necessary when focusing on a specific issue. Occurring only in the clinic is a limitation to choice B, as assessments can be conducted in various settings. Involving all body systems, as stated in choice C, is not the primary focus of a focused assessment.

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: B

Rationale: Correct Answer: B - Administer oxygen Rationale: 1. Oxygen therapy is crucial in managing COPD exacerbation to improve oxygen saturation levels. 2. Adequate oxygenation is essential to prevent further respiratory distress and potential complications. 3. Oxygen therapy helps alleviate symptoms like shortness of breath and fatigue, improving overall comfort. 4. Monitoring oxygen saturation levels guides the effectiveness of treatment and ensures appropriate oxygen delivery. Summary: - Administering corticosteroids (A) may help reduce inflammation in COPD exacerbation but does not address the immediate need for oxygen. - Monitoring respiratory rate (C) is important but prioritizing oxygen administration is more critical for immediate respiratory support. - Administering diuretics (D) may be indicated in certain cases of COPD exacerbation with fluid retention but is not the priority over oxygen therapy.