hesi health assessment test bank 2023

Correct Answer: A

Rationale: The correct first step in managing a client with acute renal failure is to administer IV fluids (Choice A). This is crucial to ensure adequate hydration and maintain renal perfusion. By administering IV fluids, you can help improve kidney function and prevent further damage. Monitoring urine output (Choice B) is important but comes after addressing the fluid balance with IV fluids. Performing a CT scan (Choice C) is not typically the initial step in managing acute renal failure as it does not directly impact the patient's immediate condition. Administering diuretics (Choice D) can worsen the condition by further reducing kidney function, so it is not the recommended first step.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. This is the priority intervention to address severe shortness of breath, ensuring the client receives adequate oxygenation. Administering oxygen helps improve oxygen saturation levels and supports respiratory function. Encouraging deep breathing (B) may exacerbate the client's distress. Elevating the head of the bed (C) can help improve breathing but does not address the immediate need for oxygen. Administering antibiotics (D) is not indicated for shortness of breath unless there is an underlying infection causing it.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. The nurse should monitor for signs such as swelling, pain, and redness in the extremities. Pneumonia (A) can occur post-stroke but is not the most common complication. Hypoglycemia (C) is more relevant for diabetic patients. Hypertension (D) is a common comorbidity in stroke patients but monitoring for DVT is crucial due to its immediate life-threatening implications.

Correct Answer: D

Rationale: The correct answer is D because all choices (A, B, and C) can increase the risk of STDs. Alcohol use can impair judgment leading to risky sexual behavior. Certain sexual practices (such as unprotected sex or having multiple partners) can directly increase the risk of STD transmission. Oral contraception does not protect against STDs, so individuals relying solely on it may still be at risk. Therefore, all of the above factors can contribute to an increased risk of contracting STDs.

Correct Answer: D

Rationale: The correct answer is D: sodium chloride. Intestinal suctioning in a client with an ileus leads to loss of fluids rich in sodium chloride. This loss can result in electrolyte imbalances and dehydration. Calcium (A), magnesium (B), and potassium (C) are not typically lost in significant amounts through intestinal suctioning in the context of an ileus. Therefore, sodium chloride is the most likely electrolyte to be lost in this scenario.