hesi health assessment test bank

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions as it acts quickly to reverse symptoms like airway swelling and low blood pressure. It helps to open airways and increase blood pressure. Antihistamines (B) are not as fast-acting as epinephrine in severe reactions. Applying a cold compress (C) is not effective in treating anaphylaxis. Placing the client in a supine position (D) can worsen breathing difficulties. Administering epinephrine is crucial in managing severe allergic reactions promptly and effectively.

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: The correct first step is to administer pain relief (Choice A) because addressing the client's pain is a top priority to ensure their comfort and well-being. Pain management is crucial post-surgery to prevent complications and aid in recovery. Monitoring vital signs (Choice B) is important but should follow pain relief to ensure the client's stability. Assessing the wound (Choice C) is necessary but not the immediate priority when the client is in acute pain. Applying a warm compress (Choice D) may provide temporary relief but does not address the underlying cause of the pain. Therefore, administering pain relief is the most appropriate initial action to alleviate the client's discomfort and start the healing process effectively.

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: A

Rationale: The correct answer is A because the purpose of health assessment is not solely to identify the client's major disease process. Health assessment also includes collecting information about the client's health status, clarifying their ability to pay for health care, and evaluating client outcomes. Identifying the disease process is just one component of a comprehensive health assessment. The other choices (B, C, D) are incorrect because they all represent valid purposes of health assessment. Collecting information about health status helps in understanding the client's overall well-being, clarifying the ability to pay for health care assists in planning appropriate care, and evaluating client outcomes is essential for monitoring progress and adjusting interventions as needed.