ATI RN
hesi health assessment test bank 2023 Questions
Question 1 of 5
What should the nurse do when a client is experiencing hyperglycemia?
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.
Question 2 of 5
What should be the first step in managing a client with suspected spinal cord injury?
Correct Answer: A
Rationale: The correct first step is to immobilize the spine (A) in a suspected spinal cord injury to prevent further damage. This helps to stabilize the spine and prevent any potential movement that could worsen the injury. Providing pain relief (B) should come after immobilization. Assessing for signs of spinal shock (C) is important but comes after immobilization. Placing the client in a supine position (D) can be part of immobilization but is not the first step.
Question 3 of 5
Which medication should be used to treat anaphylaxis?
Correct Answer: A
Rationale: The correct answer is A: Epinephrine. It is the first-line treatment for anaphylaxis as it rapidly reverses severe allergic reactions by constricting blood vessels, relaxing airway muscles, and increasing heart rate. Diphenhydramine (B) and steroids (C) are used as adjunct therapies but do not provide immediate relief like epinephrine. Albuterol (D) is used for bronchospasm in asthma, not for anaphylaxis. In summary, epinephrine is the most effective and life-saving medication for treating anaphylaxis.
Question 4 of 5
The nurse is teaching parents of a newborn about feeding their infant. Which instruction should the nurse include?
Correct Answer: A
Rationale: Rationale for Correct Answer A: 1. Using the defrost setting on microwave ovens to warm bottles is safe because it ensures even heating without creating hot spots that could burn the baby's mouth. 2. This method helps to preserve the nutrients in the breast milk or formula. 3. It is important to warm the bottle to body temperature to mimic the natural feel of breast milk for the baby's comfort. Summary of Incorrect Choices: B: Feeding the baby partially used bottles after 24 hours can increase the risk of bacterial contamination and foodborne illness. C: Mixing two parts water and one part concentrate for formula concentrate is incorrect as it may dilute the formula, leading to inadequate nutrition for the baby. D: Adding new formula to partially used bottles can alter the balance of nutrients and increase the risk of contamination, affecting the baby's health.
Question 5 of 5
What is the most important assessment for a client with diabetes and newly diagnosed hypertension?
Correct Answer: B
Rationale: The correct answer is B: Perform a comprehensive physical exam. This is important because it helps assess the overall health status of the client, including cardiovascular risk factors that can affect both diabetes and hypertension. Monitoring blood glucose (A) is important for diabetes management but not specific to newly diagnosed hypertension. Checking for protein in the urine (C) is important for assessing kidney function in diabetes, but not the most crucial assessment for newly diagnosed hypertension. Assessing for urinary retention (D) is not directly related to managing diabetes and hypertension.
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