hesi health assessment test bank

Correct Answer: C

Rationale: Correct Answer: C Rationale: By threading the IV bag and tubing through the gown sleeve, the nurse ensures that the client's IV line remains intact and secure. This method minimizes the risk of dislodging the IV line or causing discomfort to the client. It also allows for a smooth removal of the gown without compromising the IV line. Summary: A: Disconnecting tubing near the client can lead to accidental disconnection of the IV line. B: Cutting the gown with scissors is unnecessary and poses a risk of damaging the IV line. D: Disconnecting the tubing at the IV container may result in spillage of IV fluids and potential contamination.

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.

Correct Answer: D

Rationale: The correct answer is D: Objective. During a physical assessment, the nurse gathers data through observation and measurement, such as vital signs and physical appearance, which are objective and measurable. This type of data is based on facts rather than opinions or interpretations, making it reliable for assessing the client's health status. Patient-centered data (A) refers to information focused on the client's perspective, subjective data (B) is based on the client's symptoms or feelings, and unconfirmed data (C) lacks validation or evidence, making them unreliable for making clinical decisions.

Correct Answer: A

Rationale: The correct answer is A: Immobilize the spine. This is the most appropriate intervention for a client with a suspected spinal cord injury to prevent further damage. Immobilization helps stabilize the spine and reduce the risk of spinal cord compression or injury. Administering pain relief (B) or IV fluids (C) should only be done after proper spinal immobilization to avoid exacerbating the injury. Placing the client in a supine position (D) can be beneficial if done carefully after spine immobilization, but immobilizing the spine takes precedence to prevent any potential movement that could worsen the injury.

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.