hesi health assessment test bank 2023

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. In acute renal failure, maintaining adequate hydration is crucial to support kidney function and prevent further damage. IV fluids help improve renal perfusion and promote urine output. Hemodialysis may be necessary in severe cases but initial intervention is fluid resuscitation. Administering pain relief or morphine is not the priority in acute renal failure as addressing hydration status takes precedence over pain management.

Correct Answer: A

Rationale: The correct first action when a client develops a fever after surgery is to administer antipyretics (A). Fever post-surgery can indicate infection, and antipyretics help lower the body temperature. Administering pain medications (B) may mask the fever's underlying cause. Providing fluids (C) is essential but not the priority. Providing wound care (D) is important but comes after addressing the fever. Administering antipyretics promptly helps manage the fever and allows for further assessment and intervention if needed.

Correct Answer: A

Rationale: The correct answer is A because reinforcing good habits, such as healthy eating and exercise, is essential for promoting health and preventing disease. This involves educating patients on proper self-care practices. Providing medical diagnosis (B) is not a nursing role, as it falls under the domain of medical professionals. Maintaining optimal functioning (C) is important but not specific to promoting health. Prescribing treatment (D) is beyond the scope of nursing practice, as only advanced practice nurses have prescriptive authority.

Correct Answer: B

Rationale: The correct answer is B: Jaundice. Yellowish brown skin coloration along with pink coloration of the hard and soft palate is indicative of jaundice, a condition characterized by elevated levels of bilirubin in the blood. Bilirubin causes a yellowish discoloration of the skin but does not affect the color of the mucous membranes like the hard and soft palate. Pallor (A) refers to paleness of the skin due to decreased blood flow or anemia, not relevant in this case. Cyanosis (C) is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood, which is not consistent with the presented findings. Iron deficiency (D) may lead to pallor, but it does not cause yellowish brown skin coloration like jaundice.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. In hypoglycemia, the priority is to raise the low blood sugar levels quickly. Administering glucose is the most direct and effective way to do so. Glucose will rapidly increase the blood sugar levels and help the client recover from hypoglycemia. Administering insulin (B) would further lower blood sugar levels. Administering glucagon (C) is used for severe hypoglycemia when the client is unconscious. Encouraging deep breathing (D) is not effective in treating hypoglycemia and does not address the immediate need to raise blood sugar levels.