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?- Skildor

Question 1 of 5

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?

A. Leave the room and close the door to the client's room B. Assess the appearance of the client's surgical dressing C. Bring the client a prescribed PRN sedative-hypnotic D. Discuss symptoms of sleep deprivation with the client

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.

Question 2 of 5

During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?

A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. B. The client tells the nurse that she does not have much of an appetite today. C. The nurse notes that there are numerous scatter rugs throughout the house. D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

Correct Answer: C

Rationale: The presence of numerous scatter rugs throughout the house poses a significant safety hazard to the client who is ambulating with a quad cane. These rugs increase the risk of tripping and falling, making it the most critical finding that needs immediate attention to prevent potential injuries and ensure the client's safety during ambulation.

Question 3 of 5

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?

A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition the client in the Sims' position. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

Correct Answer: C

Rationale: The correct position for administering a soap suds enema is the Sims' position, not the left lateral position. The Sims' position allows the enema solution to follow the anatomical course of the intestines and provides the best overall results. By repositioning the client in the Sims' position, the weight is distributed to the anterior ilium, facilitating the enema administration process.

Question 4 of 5

The healthcare professional retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN for severe pain. How many mL should the healthcare professional administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth)

A. 0.8 mL B. 0.75 mL C. 0.7 mL D. 0.9 mL

Correct Answer: A

Rationale: To calculate the mL to administer, divide the ordered dose (3 mg) by the concentration (4 mg/mL). 3 mg � 4 mg/mL = 0.75 mL. Rounding to the nearest tenth, the correct dose to administer is 0.8 mL.

Question 5 of 5

A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?

A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. B. Instruct the UAP not to wake the client under any circumstances during the night. C. Place a 'Do Not Disturb' sign on the door and change assessments from every 4 to every 8 hours. D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.

Correct Answer: A

Rationale: The best action for the nurse is to determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. By incorporating familiar bedtime rituals that do not compromise the client's safety, the nurse can help the client fall asleep faster and improve the overall quality of care provided to the client.

HESI Fundamentals

Skildor

HESI RN

HESI RN

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