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. During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse?

Correct answer: D

Rationale: The best response for the nurse is to ask the client to talk about specific concerns. This approach provides an opportunity for the client to express her worries openly, allowing the nurse to gather more detailed information for a comprehensive assessment and to address the client's concerns effectively.

3. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

Correct answer: C

Rationale: To assess fever patterns accurately, the nurse should measure the client’s temperature at regular intervals. This approach helps in identifying the pattern of fever spikes and fluctuations, which can provide valuable information for diagnostic and treatment purposes. Assessing for flushed, warm skin or documenting circadian rhythms may not directly reveal the fever pattern, while varying temperature measurement sites could lead to inconsistent readings. Therefore, measuring temperature at regular intervals is the most appropriate intervention to identify fever patterns in this scenario.

4. The healthcare provider is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the healthcare provider include in the assessment?

Correct answer: D

Rationale: When caring for patients from diverse cultural backgrounds, it is essential to respect and consider their cultural norms and practices while providing healthcare. Understanding and incorporating cultural beliefs and values can enhance the quality of care and improve patient outcomes.

5. A client with a diagnosis of asthma is receiving albuterol (Proventil) via a metered-dose inhaler (MDI). Which assessment finding indicates that the medication is effective?

Correct answer: A

Rationale: Increased oxygen saturation (A) is the most direct indicator of the effectiveness of albuterol (Proventil) in improving breathing. Oxygen saturation reflects the amount of oxygen in the blood, showing that the albuterol is helping with air exchange in the lungs. While decreased respiratory rate (B), absence of audible wheezing (C), and improved exercise tolerance (D) are positive outcomes, they are secondary to oxygen saturation. Oxygen saturation directly reflects the improvement in the client's respiratory status and the effectiveness of the medication.

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