HESI Comprehensive Exit Practice Test Answered A+ Solution Guide

1. A client with deep partial-thickness and full-thickness burns of the face and chest is receiving wound care using the open method. The plan of care includes the Nsg Dx, "Risk for infection R/T impaired tissue integrity." Based on the expected outcome, "Client remains free of infections," which nursing interventions should the PN implement? A. Wear gown, cap, mask, and gloves during direct client care. B. Restrict visitors in order to prevent wound contamination. C. Use sterile water for debridement in the hydrotherapy tank. D. Apply sterile dressings after debridement of burn wounds. ANS : A. Wear gown, cap, mask, and gloves during direct client care. No dressing is used for burn wound care using the open method. The burn area is exposed and an aseptic environment is needed to prevent contamination and infection. Protective isolation precautions should be implemented during direct client care and wound care, which should include wearing gown, cap, mask, and gloves. 2. What action should the PN implement to facilitate speech for a client who has a fenestrated tracheostomy tube? A. Show the client how to use a tracheostomy plug. B. Determine the client's ability to swallow. C. Remove the inner cannula. D. Give oxygen at 6 L/minute via tracheostomy collar. ANS : B. Determine the client's ability to swallow. A fenestrated tracheostomy has an opening or hole on the posterior aspect of the outer cannula that allows airflow over the vocal cords and speech in a client who is spontaneously breathing. It does not have a cuff, so the client's risk for aspiration should be determined