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: A

Rationale: The correct answer is A: Administer IV fluids. This is the most important intervention for a client with severe burns because it helps maintain adequate fluid balance and prevent hypovolemic shock. IV fluids are crucial in managing burns to prevent complications such as dehydration and organ damage. Monitoring vital signs closely (B) and urine output (C) are important, but administering IV fluids takes precedence in stabilizing the client. Placing the client in a prone position (D) is not recommended for burn patients as it can increase the risk of infection and impede breathing.

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: The correct answer is B: Provide oxygen therapy. For a client with shortness of breath and a history of heart failure, oxygen therapy is the most effective intervention as it helps improve oxygenation and relieve respiratory distress. Administering diuretics may help manage fluid retention but does not directly address the breathing difficulty. Encouraging deep breathing may be beneficial for some respiratory conditions but may not be sufficient for a client with heart failure and shortness of breath. Applying oxygen therapy is similar to providing oxygen therapy and can help improve oxygen levels, but providing oxygen therapy is more specific and effective in this case.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. Hypoglycemia is low blood sugar, and administering glucose rapidly raises blood sugar levels to restore normal function. Glucagon (choice B) is used for severe hypoglycemia when the individual cannot consume oral glucose. Insulin (choice C) lowers blood sugar levels and is contraindicated in hypoglycemia. Corticosteroids (choice D) can worsen hypoglycemia by affecting glucose metabolism. Administering glucose is the most direct and effective intervention for hypoglycemia.