EXIT Comprehensive HESI PN Test Bank
1. A nurse is providing discharge teaching to a client who does not speak the
same language as the nurse.Which of the following actions should the nurse
take?
a.) Use proper medical terms when giving
instructions to the client. b.) Offer written
instructions in the client’s language
c.) Direct verbal discharge instructions to the interpreter (No,
supposed to address the pt)d.) Request that an assistive personnel
interpret that instructions for the client
<DOUBLE-CHECK it for me, confused between B&C>
Rationale PDF p175: Address the client directly when the interpreter is present,
Provide educationalmaterials and instructions in the client’s language.
2. A nurse is preparing to perform a sterile dressing change for a client. Which of
the following actions should the nurse plan to take?
a.) Don sterile gloves prior to opening sterile dressing supplies
b.) Set up the sterile field above waist level
c.) Consider 5.08cm (2 in) of the sterile field’s border
to be contaminated d.) Place the cap of a sterile
solution inside the sterile field
,3. A nurse is inserting an NG tube for a client who requires gastric decompression.
Which of the followingactions should the nurse take to verify proper placement
of the tube?
a.) Assess the client for a gag reflex
b.) Measure the pH of the gastric aspirate
c.) Place the end of the NG tube in water to observe for bubbling
d.) Auscultate 2.5cm (1 in) above the umbilicus while injecting 15 mL of sterile
water
4. A nurse is documenting in a client’s medical record. Which of the following entries
should the nurse record? a.) “Incision without redness or drainage”
b.) “Drank adequate amounts of fluid with meals”
c.) “Administered pain medication”
d.) “Oral temperature slightly elevated at 0800”
2013 - Folder 2
5. A nurse is caring for a client who has an incisional wound and a prescription for
wound care. Which of thefollowing images indicates the proper method of cleaning
a wound site.
PDF p 330: Perform wound cleansing.
- For clean wounds, such as a surgical incision, cleanse from the least
contaminated (the incision)toward the most contaminated (the
surrounding skin).
- Use gentle friction when cleansing or applying solutions to the skin to
avoid bleeding or furtherinjury to the wound.
- Although the provider might prescribe other mild cleansing agents,
isotonic solutions remainthe preferred cleansing agents.
-Never use the same gauze to cleanse across an incision or wound more
than once.
, -Do not use cotton balls and other products that shed fibers.
- If irrigating, use a piston syringe or a sterile straight catheter for deep
wounds with small openings. Apply 5 to 8 psi of pressure. A 30 to 60 mL
syringe with a 19-gauge needle provides approximately 8 psi. Use normal
saline, lactated Ringer’s, or an antibiotic/antimicrobial solution
-Remove sutures and staples.
- Administer analgesics and monitor for effective pain management.
- Administer antimicrobials (topical, systemic) and monitor for
effectiveness (reduced fever, increase in comfort, decreasing WBC
count).
-Document the location and type of wound and incision, the status of
the wound and type of drainage, the type of dressing and materials,
client teaching, and how the client tolerated theprocedure.
6. A nurse is caring for a client who has a closed wound drainage system. Which
of the following actionsshould the nurse take?
a. Press straight down on the container to create a vacuum
b. Wear sterile gloves when emptying the container
c. Reset the container with the drainage port closed
d. Maintain the drain in a dependent position to facilitate drainage
7. A nurse is teaching an older adult client who has type 2 diabetes mellitus about
how to care for corn
, And calluses on her toes. Which of the following statements by the client indicates an
understanding of theteaching?
a. I can place an oval corn pad over toes that have corns as long as i remove the
pad weekly
b. I should soak my feet in warm water daily to soften corns and calluses
c. I can apply lotion to soften calluses as long as i dont put lotion between my
toes
d. I should use an over the counter liquid medication to remove corns
Rationale PDF p205: A qualified professional should perform foot care for
clients who have diabetesmellitus to evaluate the feet and prevent injury.
Instruct clients at risk for injury to do the following: inspect the feet daily,
paying specific attention to the area between the toes; Use lukewarm water,
and dry the feet thoroughly; Apply moisturizer to the feet, but avoid applying
it between the toes; Avoid over-the-counter products that contain alcohol or
other strong chemicals; Avoid self-treating corns or calluses; Do not apply
heat unless prescribed.
8. A staff nurse is teaching a newly hired nurse about alternatives to the use of
restraints on clients who are confused. Which of the following instructions should
the staff nurse include?
a. Remove clocks from the clients room
b. Use full length side rails on the clients bed (considered a restraint)
c. Check on the client frequently while he is in the restroom (safety)
d. Encourage physical activity throughout the day to expend energy
9. A nurse is admitting a client who has tuberculosis. Which of the following
types of transmission precautions should the nurse plan to initiate?
a. Contact
b. Droplets
1. A nurse is providing discharge teaching to a client who does not speak the
same language as the nurse.Which of the following actions should the nurse
take?
a.) Use proper medical terms when giving
instructions to the client. b.) Offer written
instructions in the client’s language
c.) Direct verbal discharge instructions to the interpreter (No,
supposed to address the pt)d.) Request that an assistive personnel
interpret that instructions for the client
<DOUBLE-CHECK it for me, confused between B&C>
Rationale PDF p175: Address the client directly when the interpreter is present,
Provide educationalmaterials and instructions in the client’s language.
2. A nurse is preparing to perform a sterile dressing change for a client. Which of
the following actions should the nurse plan to take?
a.) Don sterile gloves prior to opening sterile dressing supplies
b.) Set up the sterile field above waist level
c.) Consider 5.08cm (2 in) of the sterile field’s border
to be contaminated d.) Place the cap of a sterile
solution inside the sterile field
,3. A nurse is inserting an NG tube for a client who requires gastric decompression.
Which of the followingactions should the nurse take to verify proper placement
of the tube?
a.) Assess the client for a gag reflex
b.) Measure the pH of the gastric aspirate
c.) Place the end of the NG tube in water to observe for bubbling
d.) Auscultate 2.5cm (1 in) above the umbilicus while injecting 15 mL of sterile
water
4. A nurse is documenting in a client’s medical record. Which of the following entries
should the nurse record? a.) “Incision without redness or drainage”
b.) “Drank adequate amounts of fluid with meals”
c.) “Administered pain medication”
d.) “Oral temperature slightly elevated at 0800”
2013 - Folder 2
5. A nurse is caring for a client who has an incisional wound and a prescription for
wound care. Which of thefollowing images indicates the proper method of cleaning
a wound site.
PDF p 330: Perform wound cleansing.
- For clean wounds, such as a surgical incision, cleanse from the least
contaminated (the incision)toward the most contaminated (the
surrounding skin).
- Use gentle friction when cleansing or applying solutions to the skin to
avoid bleeding or furtherinjury to the wound.
- Although the provider might prescribe other mild cleansing agents,
isotonic solutions remainthe preferred cleansing agents.
-Never use the same gauze to cleanse across an incision or wound more
than once.
, -Do not use cotton balls and other products that shed fibers.
- If irrigating, use a piston syringe or a sterile straight catheter for deep
wounds with small openings. Apply 5 to 8 psi of pressure. A 30 to 60 mL
syringe with a 19-gauge needle provides approximately 8 psi. Use normal
saline, lactated Ringer’s, or an antibiotic/antimicrobial solution
-Remove sutures and staples.
- Administer analgesics and monitor for effective pain management.
- Administer antimicrobials (topical, systemic) and monitor for
effectiveness (reduced fever, increase in comfort, decreasing WBC
count).
-Document the location and type of wound and incision, the status of
the wound and type of drainage, the type of dressing and materials,
client teaching, and how the client tolerated theprocedure.
6. A nurse is caring for a client who has a closed wound drainage system. Which
of the following actionsshould the nurse take?
a. Press straight down on the container to create a vacuum
b. Wear sterile gloves when emptying the container
c. Reset the container with the drainage port closed
d. Maintain the drain in a dependent position to facilitate drainage
7. A nurse is teaching an older adult client who has type 2 diabetes mellitus about
how to care for corn
, And calluses on her toes. Which of the following statements by the client indicates an
understanding of theteaching?
a. I can place an oval corn pad over toes that have corns as long as i remove the
pad weekly
b. I should soak my feet in warm water daily to soften corns and calluses
c. I can apply lotion to soften calluses as long as i dont put lotion between my
toes
d. I should use an over the counter liquid medication to remove corns
Rationale PDF p205: A qualified professional should perform foot care for
clients who have diabetesmellitus to evaluate the feet and prevent injury.
Instruct clients at risk for injury to do the following: inspect the feet daily,
paying specific attention to the area between the toes; Use lukewarm water,
and dry the feet thoroughly; Apply moisturizer to the feet, but avoid applying
it between the toes; Avoid over-the-counter products that contain alcohol or
other strong chemicals; Avoid self-treating corns or calluses; Do not apply
heat unless prescribed.
8. A staff nurse is teaching a newly hired nurse about alternatives to the use of
restraints on clients who are confused. Which of the following instructions should
the staff nurse include?
a. Remove clocks from the clients room
b. Use full length side rails on the clients bed (considered a restraint)
c. Check on the client frequently while he is in the restroom (safety)
d. Encourage physical activity throughout the day to expend energy
9. A nurse is admitting a client who has tuberculosis. Which of the following
types of transmission precautions should the nurse plan to initiate?
a. Contact
b. Droplets
