hesi health assessment test bank

Correct Answer: D

Rationale: The correct answer is D: Urologist consult. This is the appropriate intervention for a client with suspected genitourinary trauma and visible blood at the urethral meatus because a urologist is an expert in diagnosing and managing issues related to the genitourinary system. They can perform a thorough evaluation, order appropriate tests (such as imaging studies), and provide the necessary treatment for any potential trauma. Option A (Insert a Foley catheter) could worsen the trauma if there is an underlying injury. Option B (In and out catheter specimen) and Option C (Voided urine specimen) focus on specimen collection and do not address the potential trauma, making them inappropriate interventions in this situation. Consulting a urologist ensures proper assessment and management of the suspected genitourinary trauma.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. The nurse should first assess the client's chest pain, then administer nitroglycerin if indicated for suspected cardiac origin. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can alleviate chest pain associated with angina or myocardial infarction. Administering morphine or aspirin should come after nitroglycerin if needed. Performing an ECG is important but should not delay immediate treatment with nitroglycerin for chest pain of cardiac origin.

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: D

Rationale: The correct answer is D because breast implants can hinder mammography by obscuring the view of breast tissue, making it difficult to detect abnormalities like masses. This is due to the implants blocking the x-ray machine's view. Choice A is incorrect as discomfort is not the primary reason for interference. Choice B is incorrect as breast implants are not a contraindication to mammography but can complicate the process. Choice C is incorrect as implants are designed to be secure and are not likely to be dislodged during a mammogram.

Correct Answer: B

Rationale: The correct answer is B, removing the client from the cold environment. This is because hypothermia occurs when the body loses heat faster than it can produce it, and being in a cold environment exacerbates this process. By removing the client from the cold environment, the nurse helps stop further heat loss. Warming the client slowly (A) can be detrimental as rapid rewarming can lead to complications. Providing a warm environment (C) and applying warm blankets (D) are important interventions but should come after removing the client from the cold environment to prevent further heat loss.