hesi health assessment test bank

Correct Answer: D

Rationale: The correct answer is D: A high-fat meal. After gastric resection, high-fat meals are likely to cause rapid gastric emptying due to the delayed gastric emptying effect of fats. Fats take longer to digest compared to other nutrients, leading to slower emptying of the stomach contents. This can result in rapid emptying of the stomach post-resection. A: A high-protein meal does not necessarily cause rapid gastric emptying as proteins are digested at a moderate pace. B: A large meal regardless of nutrient content may lead to slower gastric emptying due to the increased volume. C: A high-carbohydrate meal can promote quicker gastric emptying, but it is not as likely to cause rapid emptying as high-fat meals post-gastric resection.

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.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. Hypoglycemia is low blood sugar, and administering glucose rapidly raises blood sugar levels to restore normal function. Glucagon (choice B) is used for severe hypoglycemia when the individual cannot consume oral glucose. Insulin (choice C) lowers blood sugar levels and is contraindicated in hypoglycemia. Corticosteroids (choice D) can worsen hypoglycemia by affecting glucose metabolism. Administering glucose is the most direct and effective intervention for hypoglycemia.

Correct Answer: C

Rationale: Correct Answer: C Rationale: By threading the IV bag and tubing through the gown sleeve, the nurse ensures that the client's IV line remains intact and secure. This method minimizes the risk of dislodging the IV line or causing discomfort to the client. It also allows for a smooth removal of the gown without compromising the IV line. Summary: A: Disconnecting tubing near the client can lead to accidental disconnection of the IV line. B: Cutting the gown with scissors is unnecessary and poses a risk of damaging the IV line. D: Disconnecting the tubing at the IV container may result in spillage of IV fluids and potential contamination.

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.