hesi health assessment test bank 2023

Correct Answer: A

Rationale: The correct answer is A, administer insulin, because hyperglycemia indicates high blood sugar levels which can be effectively lowered by administering insulin. Insulin helps to move glucose from the blood into cells for energy production. Administering fluids (B) can be helpful for dehydration, but it does not directly address the high blood sugar levels. Encouraging activity (C) may help lower blood sugar levels over time, but in the immediate situation, administering insulin is more effective. Encouraging deep breathing (D) does not directly address hyperglycemia and would not be the appropriate first step in managing this condition.

Correct Answer: C

Rationale: The correct answer is C: Chocolate. Chocolate is known to trigger heartburn in individuals with GERD due to its high fat content and caffeine. Fat relaxes the lower esophageal sphincter, allowing stomach acid to flow back up the esophagus, leading to heartburn. Caffeine can also relax the sphincter and trigger acid reflux. Lettuce (A) and eggs (B) are generally well-tolerated and do not commonly trigger heartburn. Butterscotch (D) may be high in fat and sugar, but it is less likely to cause heartburn compared to chocolate.

Correct Answer: A

Rationale: The correct answer is A. Older adults may have a longer story to tell due to their wealth of life experiences. This can include medical history, family background, and personal stories that may impact their health. It is important for the nurse to gather all relevant information to provide appropriate care. Choice B is incorrect because not all older adults are lonely, and the reason for a longer interview is not solely based on the need for social interaction. Choice C is incorrect because while some older adults may experience cognitive decline, it is not a blanket statement that all older adults lose mental abilities. Choice D is incorrect because hearing loss is not a universal issue among older adults, and assuming so can lead to ageist stereotypes.

Correct Answer: A

Rationale: The correct answer is A: Encouraging early ambulation. This is the priority intervention as it helps prevent complications such as blood clots and pneumonia, promotes circulation, and aids in faster recovery. Ambulation also helps maintain joint mobility and muscle strength. Administering pain medications (B) is important but not the priority. Providing wound care (C) and monitoring for infection (D) are important, but ambulation takes precedence in preventing complications.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. The priority in a severe allergic reaction is to quickly address the life-threatening symptoms like anaphylaxis. Epinephrine is the first-line treatment as it helps reverse the effects of the allergic reaction by opening airways and increasing blood pressure. Administering antihistamines (choices B and D) can help relieve itching and hives but are not as effective in treating severe symptoms. Monitoring respiratory status (choice C) is important but administering epinephrine takes precedence to stabilize the client's condition.