HESI COMPREHENSIVE PREDICTOR EXAM
1. A nurse is providing hygiene care to a bariatric patient using
chlorhexidine gluconate (CHG) wipes. Which actions
... [Show More] will the nurse take? (Select
all that apply.)
a. Do not rinse.
b. Clean under breasts.
c. Inform that the skin will feel sticky.
d. Dry thoroughly between skin folds.
e. Use two wipes for each area of the body.
ANS: A, B, C
CHG wipes are easy to use and accessible for older patients and bariatric patients,
offering a no-rinse or
-drying procedure. For a bariatric patient or a patient who is diaphoretic, provide
special attention to body areas such as beneath the woman’s breasts, in the groin,
skin folds, and perineal area, where moisture collects and irritates skin surfaces.
Use wipes as directed on package—one wipe per each area of the body. CHG can
leave the skin feeling sticky. If patients complain about its use, you need to
explain their vulnerability to infection and how CHG helps reduce occurrence of
health care–associated infection.
2. Which patients will the nurse determine are in need of perineal care? (Select
all that apply.)
a. A patient with rectal and genital surgical dressings
b. A patient with urinary and fecal incontinence
c. A circumcised male who is ambulatory
d. A patient who has an indwelling catheter
e. A bariatric patient
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ANS: A, B, D, E
Patients most in need of perineal care include those at greatest risk for acquiring
an infection (e.g., uncircumcised males, patients who have indwelling urinary
catheters, or those who are recovering from rectal or genital surgery or childbirth).
A patient with urinary and bowel incontinence needs perineal cleaning with each
episode of soiling. Bariatric patients need special attention to body areas such as
skin folds and the perineal area. In addition, women who are having a menstrual
period require perineal care. Circumcised males are not at high risk for acquiring
infection, and ambulatory patients can usually provide perineal self-care.
3. The patient must stay in bed for a bed change. Which actions will the
nurse implement? (Select all that apply.)
a. Apply sterile gloves.
b. Keep soiled linen close to uniform.
c. Advise patient will feel a lump when rolling over.
d. Turn clean pillowcase inside out over the hand holding it.
Make a modified mitered corner with sheet, blanket, and spread.
ANS: C, D, E
When making an occupied bed, advise patients they will feel a lump when turning,
turn clean pillowcase inside out, and make a modified mitered corner. Clean gloves
are used. Keep soiled linen away from uniform. [Show Less]