hesi health assessment test bank

Correct Answer: C

Rationale: Step-by-step rationale: 1. Total parenteral nutrition (TPN) can cause adrenal insufficiency. 2. Corticosteroids help prevent adrenal insufficiency in TPN patients. 3. Monitoring corticosteroid administration ensures adrenal function. 4. Monitoring blood glucose or serum glucose levels is important but not specific to TPN. 5. Dehydration can be monitored but is not directly related to TPN.

Correct Answer: A

Rationale: The correct answer is A: Provide hydration. During chemotherapy, hydration is crucial to prevent dehydration and maintain kidney function. Chemotherapy drugs can be nephrotoxic and cause electrolyte imbalances. Hydration supports drug clearance and prevents kidney damage. Administering oxygen (B) is not typically a priority unless the client is experiencing respiratory distress. Administering pain medications (C) may be important but is not the priority over hydration. Monitoring for signs of infection (D) is important but providing hydration to prevent dehydration and maintain kidney function takes precedence.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. Hypoglycemia is low blood sugar, and administering glucose rapidly raises blood sugar levels to restore normal function. Glucagon (choice B) is used for severe hypoglycemia when the individual cannot consume oral glucose. Insulin (choice C) lowers blood sugar levels and is contraindicated in hypoglycemia. Corticosteroids (choice D) can worsen hypoglycemia by affecting glucose metabolism. Administering glucose is the most direct and effective intervention for hypoglycemia.

Correct Answer: D

Rationale: The correct answer is D: Encourage deep breathing. This is because encouraging deep breathing can help alleviate anxiety and promote relaxation, which can be beneficial in managing severe chest pain. Administering nitroglycerin (A) should only be done after assessing the client's condition and confirming it is safe to do so. Providing pain relief (B) may be necessary, but addressing the root cause of the pain should be the priority. Monitoring ECG (C) is important but should come after ensuring the client's immediate needs are addressed.

Correct Answer: B

Rationale: The correct answer is B: Provide cooling measures. When caring for a client with hyperthermia, the nurse's priority is to lower the body temperature to prevent further complications. Providing cooling measures such as removing excess clothing, using fans, applying cool compresses, and encouraging hydration helps to reduce the body temperature effectively. Administering antipyretics (A and D) may be considered in some cases, but cooling measures are more immediate and effective. Administering corticosteroids (C) is not indicated in the treatment of hyperthermia. Cooling measures directly target the elevated body temperature, making it the top priority in managing hyperthermia.