hesi health assessment test bank

Correct Answer: B

Rationale: The correct hand position for performing chest vibration is to spread the fingers. This allows for a larger surface area of contact with the chest, promoting effective transmission of vibrations to loosen chest secretions. Flattening the hands would reduce the effectiveness of the vibrations by limiting contact area. Cupping the hands creates a smaller contact area and may concentrate the pressure too much in one spot, potentially causing discomfort or injury. Therefore, spreading the fingers is the optimal hand position for chest vibration technique.

Correct Answer: B

Rationale: The correct answer is B, removing the client from the cold environment. This is because hypothermia occurs when the body loses heat faster than it can produce it, and being in a cold environment exacerbates this process. By removing the client from the cold environment, the nurse helps stop further heat loss. Warming the client slowly (A) can be detrimental as rapid rewarming can lead to complications. Providing a warm environment (C) and applying warm blankets (D) are important interventions but should come after removing the client from the cold environment to prevent further heat loss.

Correct Answer: B

Rationale: The correct hand position for performing chest vibration is to spread the fingers. This allows for a larger surface area of contact with the chest, promoting effective transmission of vibrations to loosen chest secretions. Flattening the hands would reduce the effectiveness of the vibrations by limiting contact area. Cupping the hands creates a smaller contact area and may concentrate the pressure too much in one spot, potentially causing discomfort or injury. Therefore, spreading the fingers is the optimal hand position for chest vibration technique.

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: C

Rationale: The correct answer is C: Objective. Objective data in a physical assessment refers to measurable and observable information obtained through physical examination, laboratory tests, and diagnostic procedures. This type of data is crucial as it is based on facts and can be quantified. Subjective data (A) is based on the patient's feelings and experiences, while patient-centered (B) refers to care that is tailored to the individual's preferences. Diagnostic (D) data refers to information obtained through tests to determine a specific condition, which is different from the general data collected during a physical assessment.