hesi health assessment test bank -Nurselytic

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.

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: A

Rationale:
Correct
Answer: A


Rationale:
1. Calling the physician shows respect for the client's request and ensures safety.
2. Consulting the physician is important to consider any potential contraindications.
3. Ginger is a common remedy for nausea and is safe for most pregnant individuals.
4. Collaborating with the physician ensures appropriate care for the client's specific needs.

Summary of Incorrect

Choices:
- B: Dismissing home remedies may not align with the client's cultural beliefs or preferences.
- C: Herbs can be effective and safe alternatives, and the client's request should be respected.
- D: While dry crackers may help with nausea, they do not address the client's specific request for ginger.

Correct Answer: B

Rationale: The correct answer is B: Provide cooling measures. When caring for a client with hyperthermia, the nurse's priority is to lower the body temperature to prevent further complications. Providing cooling measures such as removing excess clothing, using fans, applying cool compresses, and encouraging hydration helps to reduce the body temperature effectively. Administering antipyretics (A and
D) may be considered in some cases, but cooling measures are more immediate and effective. Administering corticosteroids (
C) is not indicated in the treatment of hyperthermia. Cooling measures directly target the elevated body temperature, making it the top priority in managing hyperthermia.

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.