HESI MED SURG PROCTORED EXAMPROCTORED EXAM(LATEST-
2021): (ANSWERS VERIFIED 100% CORRECT)
• The nurse is caring for a patient with a wound. The patient appears
anxious as the nurse is preparing to change the dressing. Which action
should the nurse take?
• Turn on the television.
• Explain the procedure.
• Tell the patient “Close your eyes.”
• Ask the family to leave the room.
ANS: B
Explaining the procedure educates the patient regarding the dressing
change and involves him in the care, thereby allowing the patient some
control in decreasing anxiety. Telling the patient to close the eyes and
turning on the television are distractions that do not usually decrease a
patient’s anxiety. If the family is a support system, asking support systems
to leave the room can actually increase a patient’s anxiety.
• The nurse is cleansing a wound site. As the nurse administers the
procedure, which intervention should be included?
a.
Allow the solution to flow from the most contaminated to the least
contaminated.
• Scrub vigorously when applying noncytotoxic solution to the skin.
• Cleanse in a direction from the least contaminated area.
• Utilize clean gauze and clean gloves to cleanse a site.
, ANS: C
Cleanse in a direction from the least contaminated area, such as from the
wound or incision, to the surrounding skin. While cleansing surgical or
traumatic wounds by applying noncytotoxic solution with sterile gauze or by
irrigations is correct, vigorous scrubbing is inappropriate and can cause
damage to the skin. Use gentle friction when applying solutions to the skin,
and allow irrigation to flow from the least to the most contaminated area.
• The nurse is caring for a patient after an open abdominal aortic
aneurysm repair. The nurse requests an abdominal binder and carefully
applies the binder. Which is the best explanation for the nurse to use when 1
teaching the patient the reason for the binder?
• It reduces edema at the surgical site.
• It secures the dressing in place.
• It immobilizes the abdomen.
• It supports the abdomen.
ANS: D
The patient has a large abdominal incision. This incision will need support,
and an abdominal binder will support this wound, especially during
movement, as well as during deep breathing and coughing. A binder can be
used to immobilize a body part (e.g., an elastic bandage applied around a
sprained ankle). A binder can be used to prevent edema, for example, in an
extremity but in this case is not used to reduce edema at a surgical site. A
binder can be used to secure dressings such as elastic webbing applied around
a leg after vein stripping.
• The nurse is caring for a postoperative medial meniscus repair of the
right knee. Which action should the nurse take to assist with pain
management?
• Monitor vital signs every 15 minutes.
• Check pulses in the right foot.
2021): (ANSWERS VERIFIED 100% CORRECT)
• The nurse is caring for a patient with a wound. The patient appears
anxious as the nurse is preparing to change the dressing. Which action
should the nurse take?
• Turn on the television.
• Explain the procedure.
• Tell the patient “Close your eyes.”
• Ask the family to leave the room.
ANS: B
Explaining the procedure educates the patient regarding the dressing
change and involves him in the care, thereby allowing the patient some
control in decreasing anxiety. Telling the patient to close the eyes and
turning on the television are distractions that do not usually decrease a
patient’s anxiety. If the family is a support system, asking support systems
to leave the room can actually increase a patient’s anxiety.
• The nurse is cleansing a wound site. As the nurse administers the
procedure, which intervention should be included?
a.
Allow the solution to flow from the most contaminated to the least
contaminated.
• Scrub vigorously when applying noncytotoxic solution to the skin.
• Cleanse in a direction from the least contaminated area.
• Utilize clean gauze and clean gloves to cleanse a site.
, ANS: C
Cleanse in a direction from the least contaminated area, such as from the
wound or incision, to the surrounding skin. While cleansing surgical or
traumatic wounds by applying noncytotoxic solution with sterile gauze or by
irrigations is correct, vigorous scrubbing is inappropriate and can cause
damage to the skin. Use gentle friction when applying solutions to the skin,
and allow irrigation to flow from the least to the most contaminated area.
• The nurse is caring for a patient after an open abdominal aortic
aneurysm repair. The nurse requests an abdominal binder and carefully
applies the binder. Which is the best explanation for the nurse to use when 1
teaching the patient the reason for the binder?
• It reduces edema at the surgical site.
• It secures the dressing in place.
• It immobilizes the abdomen.
• It supports the abdomen.
ANS: D
The patient has a large abdominal incision. This incision will need support,
and an abdominal binder will support this wound, especially during
movement, as well as during deep breathing and coughing. A binder can be
used to immobilize a body part (e.g., an elastic bandage applied around a
sprained ankle). A binder can be used to prevent edema, for example, in an
extremity but in this case is not used to reduce edema at a surgical site. A
binder can be used to secure dressings such as elastic webbing applied around
a leg after vein stripping.
• The nurse is caring for a postoperative medial meniscus repair of the
right knee. Which action should the nurse take to assist with pain
management?
• Monitor vital signs every 15 minutes.
• Check pulses in the right foot.
