hesi health assessment test bank

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: Administer nitroglycerin. This is the first step in the care of a client with acute chest pain because nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can relieve chest pain associated with angina or heart attack. Administering aspirin (choice B) is important as well, but nitroglycerin is prioritized due to its immediate effect in reducing chest pain. Administering opioids (choice C) and morphine (choice D) are not recommended as first-line treatments for acute chest pain, as they can mask symptoms and delay the diagnosis of potentially life-threatening conditions.

Correct Answer: A

Rationale: The correct answer is A: Administer diuretics. Diuretics help reduce fluid overload in CHF by increasing urine output and decreasing the workload on the heart. This intervention addresses the underlying issue of fluid retention, a common problem in CHF. Monitoring vital signs (B) is important but does not directly target the primary problem of fluid overload. Monitoring respiratory rate (C) is essential in CHF, but administering diuretics takes precedence in managing fluid balance. Monitoring for arrhythmias (D) is important, but not the most crucial intervention in the management of CHF.

Correct Answer: C

Rationale: The correct answer is C: Objective. Objective data in a physical assessment refers to measurable and observable information obtained through physical examination, laboratory tests, and diagnostic procedures. This type of data is crucial as it is based on facts and can be quantified. Subjective data (A) is based on the patient's feelings and experiences, while patient-centered (B) refers to care that is tailored to the individual's preferences. Diagnostic (D) data refers to information obtained through tests to determine a specific condition, which is different from the general data collected during a physical assessment.

Correct Answer: A

Rationale: The correct answer is A: Vital signs. Assessing vital signs is crucial in a client presenting with symptoms of dehydration because it provides immediate information on the client's overall condition, including heart rate, blood pressure, respiratory rate, and temperature. Changes in vital signs can indicate the severity of dehydration and guide the nurse in determining the appropriate interventions. Summary: - B: Urine output is important in assessing dehydration but may not provide immediate information on the client's current condition compared to vital signs. - C: Skin turgor is a sign of dehydration but may not be the most accurate or immediate indicator compared to vital signs. - D: Skin color can also provide information on dehydration, but assessing vital signs gives a more comprehensive picture of the client's condition.