at 0100 on a male clients second postoperative night the client states he is unable to sleep and plans to read until feeling sleepy what action should
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Nursing Elites

HESI RN

HESI Fundamentals

1. At 0100 on a male client’s second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?

Correct answer: A

Rationale: The client has expressed a plan to read until feeling sleepy, indicating that he is managing his inability to sleep. In this situation, it is best for the nurse to respect the client's autonomy and leave the room, providing privacy and an opportunity for the client to relax and hopefully fall asleep. Closing the door can also help create a quiet environment conducive to rest.

2. The client is being taught about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Correct answer: D

Rationale: Washing hands before handling needles and syringes is a crucial aspect of standard precautions to prevent infections. This practice helps reduce the risk of transferring microorganisms from the hands to the syringes and needles, thus promoting safety during medication administration.

3. When taking a client's blood pressure, the healthcare professional is unable to distinguish the point at which the first sound was heard. What is the best action for the healthcare professional to take?

Correct answer: C

Rationale: The correct action when unable to distinguish the point of the first sound during blood pressure measurement is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. This allows blood flow to return to the extremity, ensuring a more accurate reading the second time. It is important to ensure that the cuff is fully deflated and the appropriate wait time is given to obtain an accurate blood pressure measurement.

4. A client has an elevated AST 24 hours following chest pain and shortness of breath. This is suggestive of which of the following?

Correct answer: C

Rationale: An elevated AST level following chest pain and shortness of breath is suggestive of myocardial infarction. AST is released from damaged heart muscle cells during a heart attack, indicating cardiac involvement. This enzyme is not specific to liver disease, gallbladder disease, or skeletal muscle injury in this clinical context.

5. The healthcare provider is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?

Correct answer: B

Rationale: A lactating woman (B) has the greatest need for additional protein intake. Lactation increases the metabolic demands for protein to support milk production, making it essential for the mother to have a higher protein intake. While clients in choices A, C, and D also require protein for various reasons, they do not have the same increased protein demands as a lactating woman. Choice A, a college-age track runner with a sprained ankle, may need protein for tissue repair but not at the level required during lactation. Choice C, a school-aged child with Type 2 diabetes, may benefit from protein for overall health but does not have the same increased protein needs as a lactating woman. Choice D, an elderly man being treated for a peptic ulcer, may need protein for healing but not to the extent required by a lactating woman.

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