hesi health assessment test bank

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: 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.

Correct Answer: A

Rationale: The correct answer is A (Every 24 hours) because TPN solutions are at high risk for contamination, making it crucial to change the tubing frequently to prevent infection. Changing the tubing every 24 hours helps maintain sterility and reduces the risk of microbial growth. Choices B, C, and D are incorrect because prolonging the tubing change interval increases the likelihood of bacterial colonization and poses a higher risk of infection for the patient receiving TPN. It is essential to adhere to the recommended 24-hour tubing change frequency to ensure patient safety and minimize the potential for complications.

Correct Answer: D

Rationale: The correct answer is D - unexplained vaginal bleeding. This is a contraindication for hormone replacement therapy as it could indicate a serious underlying condition such as endometrial cancer. Hormone replacement therapy can increase the risk of endometrial cancer, so it should not be used in the presence of unexplained vaginal bleeding. A, B, and C are incorrect: A: Family history of stroke is not a direct contraindication for hormone replacement therapy. It may influence the decision-making process, but it is not a definitive contraindication. B: Ovaries removed before age 45 may actually be an indication for hormone replacement therapy to manage symptoms of menopause. C: Frequent hot flashes and/or night sweats are common symptoms of menopause and are not contraindications for hormone replacement therapy.

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. Preventing infiltration of calcium is crucial to avoid tissue necrosis and sloughing. 2. Infiltration of calcium can lead to severe tissue damage and potential harm to the patient. 3. Monitoring for signs of infiltration during administration of electrolyte solutions is essential. 4. Administering calcium-containing solutions cautiously can prevent serious complications. 5. Ensuring proper placement of the IV line and monitoring for any signs of infiltration is key. Summary: A: Infusing hypertonic solutions rapidly can lead to adverse effects, such as fluid overload. B: Limiting potassium to 80 mEq per liter is important, but not directly related to preventing calcium infiltration. D: Reevaluating digitalis dosage is important in clients receiving electrolyte solutions but not directly related to preventing calcium infiltration.