HESI MATERNITY PROCTORED EXAM
1. The nurse is providing a complete bed bath to a patient using a commercial
bath cleansing pack (bag bath). What should the nurse do?
a. Rinse thoroughly.
b. Allow the skin to air-dry.
c. Do not use a bath towel.
d. Dry the skin with a towel.
ANS: B
The nurse should allow the skin to air-dry for 30 seconds. Drying the skin
with a towel removes the emollient that is left behind after the water/cleanser
solution evaporates. It is permissible to lightly cover the patient with a bath
blanket or towel to prevent chilling. Do not rinse when using a bag bath.
2. A nurse is providing perineal care to a female patient. Which washing
technique will the nurse use?
a. Back to front
In a circular motion
b. From pubic area to rectum
c. Upward from rectum to pubic area
ANS: C
Cleansing from pubic area to rectum (front to back) reduces the transfer of
microorganisms to the urinary meatus and decreases the risk of urinary tract
infection. Cleansing from rectum to pubic area or back to front increases the
risk of urinary tract infection. Circular motions are used in male perineal
care.
3. The nurse is providing perineal care to an uncircumcised male patient.
Which action will the nurse take?
a. Leave the foreskin alone because there is little chance of infection.
b. Retract the foreskin for cleansing and allow it to return on its own.
c. Retract the foreskin and return it to its natural position when done.
d. Leave the foreskin retracted. 1
, ANS: C
Return the foreskin to its natural position. Keeping the foreskin retracted leads
to tightening of the foreskin around the shaft of the penis, causing local edema
and discomfort. The foreskin may not return to its natural position on its own.
Patients at greatest risk for infection are uncircumcised males.
4. Which instruction will the nurse provide to the nursing assistive
personnel when providing foot care for a patient with diabetes?
a. Do not place slippers on the patient’s feet.
b. Trim the patient’s toenails daily.
c. Report sores on the patient’s toes.
d. Check the brachial artery.
ANS: C
Report any changes that may indicate inflammation or injury to tissue. Do
not allow the diabetic patient to go barefoot; injury can lead to amputations.
Clipping toenails is not allowed. Patients with peripheral vascular disease or
diabetes mellitus often require nail care from a specialist to reduce the risk of
infection. When assessing the patient’s feet, the nurse palpates the dorsalis
pedis of the foot, not the brachial artery.
5. The debilitated patient is resisting attempts by the nurse to provide oral
hygiene. Which action will the nurse take next?
a. Insert an oral airway.
b. Place the patient in a flat, supine position.
c. Use undiluted hydrogen peroxide as a cleaner.
d. Quickly proceed while not talking to the patient.
ANS: A
If the patient is uncooperative, or is having difficulty keeping the mouth open,
insert an oral airway. Insert it upside down, and then turn the airway sideways
and over the tongue to keep the teeth apart. Do not use force. Position the
patient on his or her side or turn the head to allow for drainage. Placing the
patient in a flat, supine position could lead to aspiration. Hydrogen peroxide is
irritating to mucosa. Even though the patient is debilitated, explain the steps
of mouth care and the sensations that he or she will feel. Also tell the patient
when the procedure is completed.
6. A nurse is providing oral care to a patient with stomatitis. Which technique
2
will the nurse use?
1. The nurse is providing a complete bed bath to a patient using a commercial
bath cleansing pack (bag bath). What should the nurse do?
a. Rinse thoroughly.
b. Allow the skin to air-dry.
c. Do not use a bath towel.
d. Dry the skin with a towel.
ANS: B
The nurse should allow the skin to air-dry for 30 seconds. Drying the skin
with a towel removes the emollient that is left behind after the water/cleanser
solution evaporates. It is permissible to lightly cover the patient with a bath
blanket or towel to prevent chilling. Do not rinse when using a bag bath.
2. A nurse is providing perineal care to a female patient. Which washing
technique will the nurse use?
a. Back to front
In a circular motion
b. From pubic area to rectum
c. Upward from rectum to pubic area
ANS: C
Cleansing from pubic area to rectum (front to back) reduces the transfer of
microorganisms to the urinary meatus and decreases the risk of urinary tract
infection. Cleansing from rectum to pubic area or back to front increases the
risk of urinary tract infection. Circular motions are used in male perineal
care.
3. The nurse is providing perineal care to an uncircumcised male patient.
Which action will the nurse take?
a. Leave the foreskin alone because there is little chance of infection.
b. Retract the foreskin for cleansing and allow it to return on its own.
c. Retract the foreskin and return it to its natural position when done.
d. Leave the foreskin retracted. 1
, ANS: C
Return the foreskin to its natural position. Keeping the foreskin retracted leads
to tightening of the foreskin around the shaft of the penis, causing local edema
and discomfort. The foreskin may not return to its natural position on its own.
Patients at greatest risk for infection are uncircumcised males.
4. Which instruction will the nurse provide to the nursing assistive
personnel when providing foot care for a patient with diabetes?
a. Do not place slippers on the patient’s feet.
b. Trim the patient’s toenails daily.
c. Report sores on the patient’s toes.
d. Check the brachial artery.
ANS: C
Report any changes that may indicate inflammation or injury to tissue. Do
not allow the diabetic patient to go barefoot; injury can lead to amputations.
Clipping toenails is not allowed. Patients with peripheral vascular disease or
diabetes mellitus often require nail care from a specialist to reduce the risk of
infection. When assessing the patient’s feet, the nurse palpates the dorsalis
pedis of the foot, not the brachial artery.
5. The debilitated patient is resisting attempts by the nurse to provide oral
hygiene. Which action will the nurse take next?
a. Insert an oral airway.
b. Place the patient in a flat, supine position.
c. Use undiluted hydrogen peroxide as a cleaner.
d. Quickly proceed while not talking to the patient.
ANS: A
If the patient is uncooperative, or is having difficulty keeping the mouth open,
insert an oral airway. Insert it upside down, and then turn the airway sideways
and over the tongue to keep the teeth apart. Do not use force. Position the
patient on his or her side or turn the head to allow for drainage. Placing the
patient in a flat, supine position could lead to aspiration. Hydrogen peroxide is
irritating to mucosa. Even though the patient is debilitated, explain the steps
of mouth care and the sensations that he or she will feel. Also tell the patient
when the procedure is completed.
6. A nurse is providing oral care to a patient with stomatitis. Which technique
2
will the nurse use?
