the nurse is preparing to provide wound care for a client which step should be done first
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Nursing Elites

HESI LPN

HESI PN Exit Exam 2024

1. The nurse is preparing to provide wound care for a client. Which step should be done first?

Correct answer: A

Rationale: The correct answer is to don procedural gloves first. Donning procedural gloves is essential to protect the nurse from contaminants while removing the old dressing. This step helps maintain aseptic technique and prevents the transfer of microorganisms. Removing the dressing (choice B) should follow after wearing gloves to prevent the spread of pathogens. Applying prescribed medications (choice C) should be done after the wound is cleaned and dressed. Donning a pair of sterile gloves (choice D) is not necessary for initial wound care; procedural gloves are sufficient for standard wound care.

2. Which nursing intervention is most appropriate for managing delirium in an elderly patient?

Correct answer: C

Rationale: Encouraging family presence is the most appropriate intervention for managing delirium in elderly patients. This intervention provides orientation, reassurance, and comfort, which can help reduce confusion and anxiety, thus aiding in managing delirium. Keeping the room brightly lit (Choice A) may worsen delirium as it can disrupt the patient's sleep-wake cycle. Administering sedatives (Choice B) should be avoided unless absolutely necessary due to the risk of worsening delirium. Restricting fluids (Choice D) is not a recommended intervention for managing delirium, as hydration is important for overall patient well-being.

3. While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness of breath. Which action should the nurse implement first?

Correct answer: C

Rationale: Having the client sit down in the hallway is the first action the nurse should implement. This is crucial to prevent further strain on the heart and to provide a safer environment for assessment and potential emergency intervention. Administering sublingual nitroglycerin (Choice A) may be appropriate later but should not precede ensuring the client's immediate safety. Assisting the client back to the room (Choice B) may not be advisable if the client is experiencing chest tightness and shortness of breath. Obtaining a 12-lead electrocardiogram (Choice D) is important but would not be the initial action to address the client's immediate symptoms.

4. The nurse enters a male client's room to administer routine morning medications, and the client is on the phone. Which action is best for the nurse to take?

Correct answer: B

Rationale: The best action for the nurse to take in this situation is to wait for the client to excuse himself from the telephone conversation and then observe the client taking the medication. This approach ensures that the client takes the medication as prescribed, promoting compliance and safety. Choice A is not ideal as it involves unnecessary delegation and may lead to confusion. Choice C is incorrect because assuming refusal without direct communication can compromise patient care. Choice D is not recommended as leaving the medication with the client unsupervised may result in non-compliance or potential errors.

5. The PN is reviewing care instructions with a client who has diabetic retinopathy and is experiencing glare around lights. What should the PN reinforce with the client?

Correct answer: B

Rationale: The correct answer is B. Avoiding driving at night is recommended for clients experiencing glare around lights due to diabetic retinopathy. This can help reduce the risk of accidents and visual discomfort. Making adjustments to the personal schedule to avoid nighttime driving is a practical approach to manage the glare. Choices A, C, and D are incorrect because covering eyes with compresses, exerting pressure on the inner canthus, or applying an eye shield are not effective strategies for managing glare associated with diabetic retinopathy.

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