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: 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: 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 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.

Correct Answer: A

Rationale: The correct answer is A: Administer antipyretics. The nurse should first address the fever to prevent potential complications. Antipyretics help reduce fever and discomfort quickly. Monitoring vital signs (B) is important but treating the fever takes precedence. Administering fluids (C) is essential, but addressing the fever is the priority. Administering IV antibiotics (D) may be necessary if the fever is due to infection, but confirming the cause and starting treatment can come after addressing the fever.