hesi health assessment test bank

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Calling the physician shows respect for the client's request and ensures safety. 2. Consulting the physician is important to consider any potential contraindications. 3. Ginger is a common remedy for nausea and is safe for most pregnant individuals. 4. Collaborating with the physician ensures appropriate care for the client's specific needs. Summary of Incorrect Choices: - B: Dismissing home remedies may not align with the client's cultural beliefs or preferences. - C: Herbs can be effective and safe alternatives, and the client's request should be respected. - D: While dry crackers may help with nausea, they do not address the client's specific request for ginger.

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: Provide tracheostomy care. This is the priority because maintaining the patency of the airway is crucial in a client with a tracheostomy. Tracheostomy care includes monitoring for any signs of respiratory distress, ensuring the tube is secure, assessing for any obstructions, and providing appropriate humidification. Suctioning the airway (choice B) and suctioning the tracheostomy (choice D) are important interventions but come after ensuring proper tracheostomy care. Changing the dressing (choice C) is also important but not as immediate as ensuring the airway remains clear and functional.

Correct Answer: B

Rationale: The correct answer is B: Provide cooling measures. When caring for a client with hyperthermia, the nurse's priority is to lower the body temperature to prevent further complications. Providing cooling measures such as removing excess clothing, using fans, applying cool compresses, and encouraging hydration helps to reduce the body temperature effectively. Administering antipyretics (A and D) may be considered in some cases, but cooling measures are more immediate and effective. Administering corticosteroids (C) is not indicated in the treatment of hyperthermia. Cooling measures directly target the elevated body temperature, making it the top priority in managing hyperthermia.

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.