hesi health assessment test bank

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. Nitroglycerin is the priority action for a client with a suspected myocardial infarction as it helps dilate coronary arteries, improving blood flow to the heart muscle. This helps reduce chest pain and minimize myocardial damage. Administering fluids (B) may be necessary but not the priority. Placing the client in a sitting position (C) could worsen symptoms. Administering aspirin (D) is important but not as immediate as nitroglycerin for acute pain relief.

Correct Answer: A

Rationale: The correct answer is A: Place the client on their side. This is the first nursing action for a client who develops a seizure to prevent aspiration and maintain an open airway. Placing the client on their side helps to keep their airway clear and prevents them from choking on saliva or vomit. Choice B, loosening clothing, is important but not the first priority. Choice C, placing the client in a Trendelenburg position, is not recommended as it may increase intracranial pressure. Choice D, placing the client in a sitting position, can increase the risk of injury during a seizure.

Correct Answer: D

Rationale: The correct answer is D. When a client refuses medication, the nurse should document the refusal for legal and communication purposes. Informing the healthcare provider ensures ongoing assessment and potential alternatives. Choice A lacks communication with the healthcare team. Choice B may not address the underlying issue. Choice C assumes alternative treatment is necessary without further evaluation.

Correct Answer: A

Rationale: The correct answer is A: Administer antipyretics. The nurse should first address the fever to prevent potential complications. Antipyretics help reduce fever and discomfort quickly. Monitoring vital signs (B) is important but treating the fever takes precedence. Administering fluids (C) is essential, but addressing the fever is the priority. Administering IV antibiotics (D) may be necessary if the fever is due to infection, but confirming the cause and starting treatment can come after addressing the fever.

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.