the nurse is teaching an obese client newly diagnosed with arteriosclerosis about reducing the risk of a heart attack or stroke which health promotion
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Nursing Elites

HESI RN

HESI Fundamentals

1. The client, who is newly diagnosed with arteriosclerosis and is obese, is being educated by the nurse on reducing the risk of a heart attack or stroke. Which health promotion brochure should the nurse provide to this client?

Correct answer: C

Rationale: The most significant risk factor contributing to arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Therefore, the most crucial brochure for the nurse to provide to the client focuses on decreasing cholesterol levels through diet to help reduce the risk of heart attack or stroke.

2. When a male client mentions his foot is hurting while watching TV with his wife, how should the nurse respond?

Correct answer: A

Rationale: The correct response is to ask the client to rate his pain on a scale of 1 to 10. This helps the nurse assess the intensity of the pain and determine the appropriate pain medication. Encouraging him to wait or attend to another client's needs first are incorrect because pain management should be addressed promptly. Instructing on deep breathing exercises may be helpful but is not the initial step in addressing acute pain.

3. An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?

Correct answer: D

Rationale: The essential nursing measure for a client with a fractured left hip on strict bedrest is to gently lift the client when moving into a desired position (D). This helps to avoid shearing forces and prevents further injury. Massaging reddened areas (A) should be avoided to prevent skin damage. Active range of motion exercises (B) may be limited due to pain and muscle spasms in the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip as it may cause additional harm.

4. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?

Correct answer: A

Rationale: The priority nursing action is to restore circulation by loosening the restraint (A) because blue fingers (cyanosis) indicate decreased circulation. Comparing hand color bilaterally (C) and palpating the right radial pulse (D) are important assessments to gather more information, but they do not have the priority of addressing the decreased circulation by loosening the restraint. Applying a pulse oximeter (B) is not indicated in this scenario as it measures the saturation of hemoglobin with oxygen, which is not relevant when cyanosis is related to mechanical compression from the restraints.

5. A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client?

Correct answer: C

Rationale: When a client is on contact precautions due to an infected draining wound, it is important to prevent contact with wound secretions. Therefore, disposing of soiled dressings in securely closed plastic bags helps contain and prevent the spread of infectious material, reducing the risk of transmission to others in the household.

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