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• The nurse instructs unlicensed assistive personnel (UAP) to turn an
immobilized elderly client with an indwelling urinary catheter every two
hours. What additional action should the nurse instruct the UAP to take
each time the client is turned?
• Empty the urinary drainage bag
• Feed the client a snack
• Offer the client oral fluids
• Assess the breath sounds
• Rationale: Increasing oral fluid intake reduces the risk of problems
associated with immobility, so the UAP should be instructed to offer
the client oral fluids every two hours, or whenever turning he client.
It is not necessary to empty the urinary bag or feed the client every
two hours. Assessment is a nursing function, and UAPs do not have
the expertise to perform assessment of breath sounds.
• The nurse is preparing a client who had a below-the-knee (BKA)
amputation for discharge to home. Which recommendations should the
nurse provide this client? (Select all that apply)
• Inspect skin for redness
• Use a residual limb shrinker
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,HESI Exit RN Exam over 700 Questions and
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• Apply alcohol to the stump after bathing
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,HESI Exit RN Exam over 700 Questions and
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• Wash the stump with soap and water
• Avoid range of motion exercises
• Rationale: Several actions are recommended for home care following
an amputation. The skin should be inspected regularly for
abnormalities such as redness, blistering, or abrasions. A residual
limb shrinker should be applied over the stump to protect it and
reduce edema. The stump should be washed daily with a mild soap
and carefully rinse and dried. The client should avoid cleansing with
alcohol because it can dry and crack the skin. Range of motion
should be done daily.
• When assessing the surgical dressing of a client who had abdominal
surgery the previous day, the nurse observes that a small amount of
drainage is present on the dressing and the wound’s Hemovac suction
device is empty with the plug open. How should the nurse respond?
• Replace the dressing and remove the drainage device
• Reposition the drainage device and keep the plug open
• Notify the healthcare provider that the drain is not working
• Recompress the wound suction device and secure to plug
• Rationale: The plug of a wound suction device, such as a
Hemovac, should be closed after compressing the device to apply
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, HESI Exit RN Exam over 700 Questions and
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gentle suction in a closed surgical wound to facilitate the
evacuation of subcutaneous fluids into the device. Compressing the
device and securing the plug should restore function of the closed
wound device. A small amount of drainage should be marked on
the dressing, but replacing the dressing is not necessary and the
nurse should not remove the device. Other options are not
indicated.
• A mother brings her 4-month-old son to the clinic with a quarter taped
over his umbilicus, and tells the nurse the quarter is supposed to fix her
child’s hernia. Which explanations should the nurse provide?
• This hernia is a normal variation that resolves without treatment.
• Restrictive clothing will be adequate to help the hernia go away.
• An abdominal binder can be worn daily to reduce the protrusion.
• The quarter should be secured with an elastic bandage wrap.
• Rational: an umbilical hernia is a normal variation in infants that
occurs due to an incomplete fusion of the abdominal musculature
through the umbilical ring that usually resolves spontaneously as the
child learns to walk. Other choices are ineffective and unnecessary.
HESI Exit RN Exam over 700 Questions and
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