hesi health assessment test bank

Correct Answer: A

Rationale: The correct answer is A: Administer antiepileptics. Administering antiepileptics is the priority nursing action for a client with a history of seizures to prevent seizure recurrence. Antiepileptics help control and manage seizure activity effectively. Monitoring vital signs (B) and placing the client in a lateral position (C) are important actions during a seizure but are not the priority over administering antiepileptics. Providing seizure precautions (D) is also important but does not directly address the immediate need of administering antiepileptics to prevent a seizure.

Correct Answer: D

Rationale: The correct answer is D: Urologist consult. This is the appropriate intervention for a client with suspected genitourinary trauma and visible blood at the urethral meatus because a urologist is an expert in diagnosing and managing issues related to the genitourinary system. They can perform a thorough evaluation, order appropriate tests (such as imaging studies), and provide the necessary treatment for any potential trauma. Option A (Insert a Foley catheter) could worsen the trauma if there is an underlying injury. Option B (In and out catheter specimen) and Option C (Voided urine specimen) focus on specimen collection and do not address the potential trauma, making them inappropriate interventions in this situation. Consulting a urologist ensures proper assessment and management of the suspected genitourinary trauma.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. Anticoagulants help prevent the blood clot from getting larger and reduce the risk of it breaking loose and causing a pulmonary embolism. Other choices are incorrect because B: Monitoring vital signs alone does not treat the DVT, C: Providing bed rest can increase the risk of complications like pulmonary embolism, and D: Administering fibrinolytics is not the first-line treatment for DVT.

Correct Answer: A

Rationale: The correct answer is A: Creatinine. Creatinine is a waste product produced by muscles and excreted by the kidneys. An elevated creatinine level indicates impaired kidney function, making it a key indicator for early detection of renal failure. Blood urea nitrogen (BUN) can also be elevated in renal failure, but creatinine is a more specific and sensitive marker. Sodium and potassium levels are not directly related to renal failure detection.

Correct Answer: A

Rationale: The correct answer is A: Provide tracheostomy care. This is the priority because maintaining the patency of the airway is crucial in a client with a tracheostomy. Tracheostomy care includes monitoring for any signs of respiratory distress, ensuring the tube is secure, assessing for any obstructions, and providing appropriate humidification. Suctioning the airway (choice B) and suctioning the tracheostomy (choice D) are important interventions but come after ensuring proper tracheostomy care. Changing the dressing (choice C) is also important but not as immediate as ensuring the airway remains clear and functional.