hesi health assessment test bank

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. In shock, the priority nursing action is to restore intravascular volume to improve tissue perfusion. IV fluids help increase blood pressure and cardiac output, addressing the underlying cause of shock. Monitoring vital signs (B) is important but administering fluids takes precedence. Administering fluids (C) is a general term and does not specify the urgency of IV fluids. Administering blood transfusion (D) may be indicated in certain types of shock but is not the initial priority.

Correct Answer: C

Rationale: The correct answer is C: perimenopause. Perimenopause is the transitional phase leading to menopause, characterized by irregular menstrual cycles. Climacteric refers to the period of reproductive senescence, not just irregular menses. Menopause is the cessation of menstruation for 12 consecutive months. Postmenopause is the period after menopause, not characterized by irregular menses. Assessing for symptoms of perimenopause in a woman with irregular menses over the past six months is important to understand the hormonal changes and potential menopausal symptoms she may be experiencing.

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. Preventing infiltration of calcium is crucial to avoid tissue necrosis and sloughing. 2. Infiltration of calcium can lead to severe tissue damage and potential harm to the patient. 3. Monitoring for signs of infiltration during administration of electrolyte solutions is essential. 4. Administering calcium-containing solutions cautiously can prevent serious complications. 5. Ensuring proper placement of the IV line and monitoring for any signs of infiltration is key. Summary: A: Infusing hypertonic solutions rapidly can lead to adverse effects, such as fluid overload. B: Limiting potassium to 80 mEq per liter is important, but not directly related to preventing calcium infiltration. D: Reevaluating digitalis dosage is important in clients receiving electrolyte solutions but not directly related to preventing calcium infiltration.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Calling the physician shows respect for the client's request and ensures safety. 2. Consulting the physician is important to consider any potential contraindications. 3. Ginger is a common remedy for nausea and is safe for most pregnant individuals. 4. Collaborating with the physician ensures appropriate care for the client's specific needs. Summary of Incorrect Choices: - B: Dismissing home remedies may not align with the client's cultural beliefs or preferences. - C: Herbs can be effective and safe alternatives, and the client's request should be respected. - D: While dry crackers may help with nausea, they do not address the client's specific request for ginger.

Correct Answer: C

Rationale: The correct answer is C: perimenopause. Perimenopause is the transitional period before menopause when a woman's body begins to produce less estrogen. This can lead to irregular menstrual cycles and other symptoms such as hot flashes, night sweats, and mood changes. Assessing for symptoms of perimenopause in a woman reporting irregular menses for six months is appropriate as it aligns with the timing and characteristics of this phase. Explanation for incorrect choices: A: Climacteric refers to the period of menopausal transition and is not specific to the symptoms mentioned in the scenario. B: Menopause is the cessation of menstrual periods for 12 consecutive months and is not typically associated with irregular menses. D: Postmenopause is the period after menopause has been established for at least 12 months and irregular menses would not be expected during this phase.