hesi health assessment test bank

Correct Answer: A

Rationale: The correct answer is A (Every 24 hours) because TPN solutions are at high risk for contamination, making it crucial to change the tubing frequently to prevent infection. Changing the tubing every 24 hours helps maintain sterility and reduces the risk of microbial growth. Choices B, C, and D are incorrect because prolonging the tubing change interval increases the likelihood of bacterial colonization and poses a higher risk of infection for the patient receiving TPN. It is essential to adhere to the recommended 24-hour tubing change frequency to ensure patient safety and minimize the potential for complications.

Correct Answer: C

Rationale: The correct answer is C: perimenopause. Perimenopause is the transitional phase leading to menopause, characterized by irregular menstrual cycles. Climacteric refers to the period of reproductive senescence, not just irregular menses. Menopause is the cessation of menstruation for 12 consecutive months. Postmenopause is the period after menopause, not characterized by irregular menses. Assessing for symptoms of perimenopause in a woman with irregular menses over the past six months is important to understand the hormonal changes and potential menopausal symptoms she may be experiencing.

Correct Answer: A

Rationale: Correct Answer: A - Administer antiemetics Rationale: The priority nursing action for a client vomiting post-surgery is to administer antiemetics to control nausea and vomiting, preventing complications like dehydration and electrolyte imbalance. Antiemetics help the client feel more comfortable and promote recovery. Administering fluids (choices B and C) is important, but addressing the vomiting itself takes precedence. Pain relief (choice D) is essential, but not the priority in this case.

Correct Answer: B

Rationale: Rationale: 1. GERD: Lying down after eating can worsen symptoms due to acid reflux. Sitting up helps prevent acid reflux. 2. Dumping Syndrome: Lying down can exacerbate symptoms like nausea and dizziness. Sitting up aids in digestion. 3. Choice B recommends lying down 1 hour after eating for Dumping Syndrome and sitting up at least 30 minutes after eating for GERD, which aligns with the management of both conditions. Summary: - Choice A is incorrect as lying flat after meals worsens GERD and Dumping Syndrome symptoms. - Choice C is incorrect as sitting up only after meals does not address the specific needs of GERD and Dumping Syndrome. - Choice D is incorrect as lying down after meals is not recommended for either condition.

Correct Answer: A

Rationale: The correct answer is A because capillary refill, warm toes, and no discomfort indicate good circulation and nerve function under the cast. This assessment helps detect any complications like impaired circulation or nerve damage. Posterior tibial pulses and moisture are not directly related to cast assessment. Pain threshold is subjective and does not provide objective information. Discomfort of the metacarpals is specific and not a comprehensive assessment.