hesi health assessment test bank

Correct Answer: A

Rationale: The correct answer is A: Creatinine. Creatinine is a waste product produced by muscles and excreted by the kidneys. An elevated creatinine level indicates impaired kidney function, making it a key indicator for early detection of renal failure. Blood urea nitrogen (BUN) can also be elevated in renal failure, but creatinine is a more specific and sensitive marker. Sodium and potassium levels are not directly related to renal failure detection.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. This is the most important intervention for a client with severe burns because it helps maintain adequate fluid balance and prevent hypovolemic shock. IV fluids are crucial in managing burns to prevent complications such as dehydration and organ damage. Monitoring vital signs closely (B) and urine output (C) are important, but administering IV fluids takes precedence in stabilizing the client. Placing the client in a prone position (D) is not recommended for burn patients as it can increase the risk of infection and impede breathing.

Correct Answer: A

Rationale: The correct answer is A: Vital signs. Assessing vital signs is crucial in a client presenting with symptoms of dehydration because it provides immediate information on the client's overall condition, including heart rate, blood pressure, respiratory rate, and temperature. Changes in vital signs can indicate the severity of dehydration and guide the nurse in determining the appropriate interventions. Summary: - B: Urine output is important in assessing dehydration but may not provide immediate information on the client's current condition compared to vital signs. - C: Skin turgor is a sign of dehydration but may not be the most accurate or immediate indicator compared to vital signs. - D: Skin color can also provide information on dehydration, but assessing vital signs gives a more comprehensive picture of the client's condition.

Correct Answer: D

Rationale: The correct answer is D because breast implants can hinder mammography by obscuring the view of breast tissue, making it difficult to detect abnormalities like masses. This is due to the implants blocking the x-ray machine's view. Choice A is incorrect as discomfort is not the primary reason for interference. Choice B is incorrect as breast implants are not a contraindication to mammography but can complicate the process. Choice C is incorrect as implants are designed to be secure and are not likely to be dislodged during a mammogram.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. This is the first step in the care of a client with acute chest pain because nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can relieve chest pain associated with angina or heart attack. Administering aspirin (choice B) is important as well, but nitroglycerin is prioritized due to its immediate effect in reducing chest pain. Administering opioids (choice C) and morphine (choice D) are not recommended as first-line treatments for acute chest pain, as they can mask symptoms and delay the diagnosis of potentially life-threatening conditions.