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: 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.

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: 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: C

Rationale: The correct answer is C because promoting health in the client is essential in achieving high-level wellness. Nurses play a crucial role in educating, empowering, and supporting clients in making healthy lifestyle choices. By promoting health, nurses help clients prevent illness, maintain optimal well-being, and improve their overall quality of life. Encouraging appointment attendance (choice A) is important but not solely focused on wellness promotion. Providing information on alternative treatments (choice B) is valuable but may not directly contribute to high-level wellness. Providing good client care (choice D) is a fundamental nursing responsibility, but it does not specifically address the promotion of health and wellness.