a client presents to the clinic with a large abscess on the right thigh the healthcare provider incises and drains the abscess which instruction shoul
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Nursing Elites

HESI RN

HESI Exit Exam RN Capstone

1. A client presents to the clinic with a large abscess on the right thigh. The healthcare provider incises and drains the abscess. Which instruction should the nurse provide to the client upon discharge?

Correct answer: B

Rationale: After incision and drainage of an abscess, it is crucial to perform daily wound care and dressing changes to prevent infection and promote healing. Avoiding showering until the wound is completely closed (choice A) may not be practical or necessary. Applying heat to the wound (choice C) can increase the risk of infection and delay healing. While taking the prescribed antibiotic (choice D) is important, wound care and dressing changes are more directly related to promoting healing and preventing complications.

2. An older client who had a subtotal parathyroidectomy is preparing for discharge. What finding requires immediate provider notification?

Correct answer: D

Rationale: A positive Chvostek's sign indicates hypocalcemia, a complication after parathyroid surgery that requires immediate attention. This sign is manifested by facial muscle twitching when the facial nerve in front of the ear is tapped, indicating neuromuscular irritability due to low calcium levels. Afebrile with a normal pulse (Choice A) is a normal finding and does not require immediate notification. No bowel movement since surgery (Choice B) is common postoperatively due to anesthesia effects and pain medications and usually resolves within a few days; it does not require immediate notification unless accompanied by other concerning symptoms. No appetite for breakfast (Choice C) is a common postoperative finding and does not require immediate notification unless it persists and leads to dehydration or malnutrition.

3. A client with hypothyroidism is prescribed levothyroxine. What instruction should the nurse provide?

Correct answer: A

Rationale: The correct answer is A: 'Take the medication in the morning before eating.' Levothyroxine should be taken on an empty stomach in the morning for optimal absorption. Choice B is incorrect because while taking medication with water is generally recommended, levothyroxine specifically needs to be taken on an empty stomach. Choice C is incorrect as taking levothyroxine with food can interfere with its absorption. Choice D is incorrect as levothyroxine should be taken regularly as prescribed, not only when symptoms worsen.

4. The nurse is providing care for a client with suspected deep vein thrombosis (DVT) in the left leg. Which action should the nurse take first?

Correct answer: C

Rationale: Elevating the affected leg promotes venous return and reduces swelling, which is a priority intervention for a client with suspected DVT. This action helps prevent the thrombus from dislodging and causing further complications. Encouraging ambulation may dislodge the clot, leading to a pulmonary embolism. Applying a warm compress can increase blood flow to the area, potentially dislodging the clot. Administering anticoagulants is essential but should not be the first action as elevation helps to reduce the risk of complications associated with DVT.

5. The nurse is providing care for a client with a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse implement to prevent complications associated with the tube?

Correct answer: D

Rationale: Flushing the PEG tube with water before and after feedings helps prevent clogging and maintains tube patency. Proper flushing is essential for avoiding complications related to tube blockages. Elevating the head of the bed is important for preventing aspiration during and after feedings, not specifically related to PEG tube complications. Aspirating gastric contents before administering medications is not routinely recommended for PEG tube care. Clamping the tube between feedings can lead to tube occlusion and is not a standard practice in PEG tube care.

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