Correct Answer: B

Rationale: The correct answer is B: increased fibrinogen. Heparin therapy works by inhibiting clot formation by enhancing the activity of antithrombin III, which leads to decreased levels of fibrinogen. Therefore, an increase in fibrinogen levels would indicate a positive response to Heparin therapy. Incorrect choices: A: increased platelet count - Heparin therapy does not typically affect platelet count, so an increase in platelet count would not indicate a positive response to Heparin therapy. C: decreased fibrin split products - Decreased fibrin split products may not necessarily indicate a positive response to Heparin therapy, as other factors can also influence their levels. D: decreased bleeding - While decreased bleeding can be a positive outcome of Heparin therapy, it is not a direct assessment finding that indicates a positive response to the therapy.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates active listening and empathy by directly addressing the patient's concern. By asking the patient to point to where it hurts, the nurse can gather specific information to assess the location and severity of the pain. This helps in determining potential causes and appropriate interventions. Choice B is incorrect as it delays addressing the patient's immediate concern. Choice C focuses on dietary history, which may not be relevant to the current pain complaint. Choice D is unrelated to the current issue and does not address the patient's pain directly.

Correct Answer: A

Rationale: The correct answer is A: Administer pain relief. The nurse's first priority is to address pain and ensure the client's comfort and well-being. Pain relief helps reduce distress, improve communication, and prevent complications. Monitoring blood pressure (B) and providing hydration (C) are important but not the immediate priority in severe trauma. Administering a blood transfusion (D) may be necessary but is not the first priority compared to addressing pain and stabilizing the client.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. The nurse should monitor for signs such as swelling, pain, and redness in the extremities. Pneumonia (A) can occur post-stroke but is not the most common complication. Hypoglycemia (C) is more relevant for diabetic patients. Hypertension (D) is a common comorbidity in stroke patients but monitoring for DVT is crucial due to its immediate life-threatening implications.

Correct Answer: B

Rationale: The correct answer is B: Administering oxygen as prescribed. Oxygen therapy is a critical intervention in pneumonia to improve oxygenation and prevent hypoxia. Priority is given to interventions that address the immediate physiological needs of the patient. Encouraging fluid intake (A) is important but not as urgent as oxygen therapy. Encouraging ambulation (C) can be beneficial for overall health but may not be suitable for a patient with pneumonia. Providing pain medication (D) is important for comfort but is not the priority in this case.