HESI Fundamentals Quizlet

Correct Answer: A

Rationale: Epigastric pain that radiates to the back (A) is the hallmark assessment finding of acute pancreatitis. The pancreas lies retroperitoneally in the upper abdomen, so inflammation often causes severe epigastric pain that radiates through to the back. Abdominal pain with guarding (B), nausea and vomiting (C), and increased bowel sounds (D) can also be present in acute pancreatitis but are less specific and may be seen in various other gastrointestinal conditions.

Correct Answer: A

Rationale: Monitoring daily weights is an accurate method to assess the effectiveness of fluid replacement therapy because changes in weight reflect changes in fluid balance. Fluid volume deficit can be objectively evaluated by monitoring daily weights as it provides a more precise measurement of fluid status over time.

Correct Answer: C

Rationale: When the nurse observes that the client's skin over the sternum 'tents' when gently pinched, it is a classic sign of fluid volume deficit. The appropriate action for the nurse in this situation is to continue the planned nursing interventions aimed at restoring the client's fluid volume. This finding reinforces the need to address the fluid deficit and support the client's recovery.

Correct Answer: B

Rationale: In this situation, the nurse's initial action should be to reassess the client to evaluate if restraints are still required before considering reapplication. This step ensures that the restraints are only used when absolutely necessary, promoting the client's safety and autonomy. Documentation and monitoring are essential, but reassessment of the client's condition takes precedence to provide individualized care.

Correct Answer: D

Rationale: The correct action for the nurse to take first in this situation is to compare the current blood pressure reading with the client's previously documented readings. This comparison will provide valuable information about what is normal for this specific client, helping to determine if the current reading represents a significant change or if it falls within the client's usual range. This step is essential for appropriate decision-making and planning further care.