before preparing a client for the first surgical case of the day a part time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub
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Nursing Elites

HESI RN

HESI RN Exit Exam

1. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3-minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?

Correct answer: D

Rationale: The correct answer is to direct the nurse to continue the surgical hand scrub for a 5-minute duration. Surgical hand scrubs should last for 5 to 10 minutes, ensuring thorough cleaning and disinfection. Choice A is incorrect because the nurse should be guided to complete the scrub properly rather than having someone else do it. Choice B is incorrect as it does not address the duration of the hand scrub. Choice C is incorrect as it suggests a 3-minute hand scrub is sufficient, which is inadequate for proper preparation before surgery.

2. A client with cirrhosis is admitted with jaundice and ascites. Which clinical finding is most concerning?

Correct answer: B

Rationale: Confusion and altered mental status are concerning in a client with cirrhosis as they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Increased abdominal girth can be seen in ascites, yellowing of the skin is due to jaundice, and peripheral edema is associated with fluid retention in cirrhosis, but confusion and altered mental status are more closely linked to hepatic encephalopathy, which can progress rapidly and needs urgent attention.

3. For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action?

Correct answer: A

Rationale: The correct answer is A. Tented skin turgor is a sign of dehydration, which can be exacerbated by the use of antidiarrheals in clients with gastroenteritis. In dehydration, the skin loses its elasticity and becomes less resilient when pinched. Therefore, the nurse should take immediate action upon noticing tented skin turgor to prevent further complications. Choices B, C, and D are incorrect because decreased bowel sounds, persistent diarrhea, and dehydration are expected findings in a client with gastroenteritis who has been administered an antidiarrheal agent.

4. The nurse is assessing a client with left-sided heart failure. Which assessment finding requires immediate intervention?

Correct answer: C

Rationale: In a client with left-sided heart failure, crackles in the lungs are a critical assessment finding that necessitates immediate intervention. Crackles indicate pulmonary congestion, a sign of worsening heart failure that requires prompt attention to prevent respiratory distress. Jugular venous distention, shortness of breath, and peripheral edema are also common in heart failure, but crackles specifically point to pulmonary involvement and the urgent need for intervention.

5. The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which assessment finding is most concerning?

Correct answer: C

Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, an elevated blood pressure is the most concerning assessment finding. This finding can indicate worsening hypertension, which requires prompt intervention to prevent complications such as cardiovascular events or further kidney damage. Increased fatigue (Choice A) is a common symptom in CKD and can be expected with the condition itself or the treatment. Headache (Choice B) can also occur but is less specific to CKD or its treatment. Low urine output (Choice D) is a concern in CKD but may not be directly related to erythropoietin therapy.

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