the nurse is teaching a client with a below the knee amputation about proper care of the residual limb the most important point to emphasize would be the nurse is teaching a client with a below the knee amputation about proper care of the residual limb the most important point to emphasize would be
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Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Capstone

1. The client with a below-the-knee amputation is being taught about proper care of the residual limb. The most important point to emphasize would be

Correct answer: B

Rationale: The correct answer is B: Keep the skin on the stump clean and dry. This is crucial for preventing infection and promoting healing of the residual limb. Wrapping the stump with an elastic bandage can constrict blood flow and cause issues. Using alcohol to cleanse the stump daily can be too harsh and drying for the skin, leading to irritation. Applying moisturizing lotion daily is not as essential as keeping the skin clean and dry to prevent complications.

2. The Gravindex test is used to detect Human Chorionic Gonadotrophic hormone (HCG) in:

Correct answer: A

Rationale: The correct answer is A: Urine or whole blood. The Gravindex test is designed to detect Human Chorionic Gonadotrophic hormone (HCG) in urine or whole blood samples. HCG is a hormone produced during pregnancy, and its presence in urine or blood can indicate pregnancy. Choices B, C, and D are incorrect as the Gravindex test is not intended to detect HCG in amniotic fluid, saliva, or cervical mucus. These bodily fluids are not typically used for pregnancy testing purposes.

3. A client with a postoperative wound that eviscerated yesterday has an elevated temperature. What is the most important intervention for the nurse to implement?

Correct answer: B

Rationale: Obtaining a wound swab for culture and sensitivity is the most important intervention in this situation. It helps identify the presence of infection in the postoperative wound that could be causing the elevated temperature. By obtaining a wound swab, healthcare providers can determine the appropriate treatment needed to address any infection. Initiating contact isolation (Choice A) may be necessary in certain situations but is not the priority in this case. Assessing temperature (Choice C) is important but does not directly address the underlying cause of the elevated temperature. Using alcohol-based solutions for hand hygiene (Choice D) is a standard practice for infection control but is not the most crucial intervention in this scenario.

4. The practical nurse (PN) is caring for an adolescent who has been diagnosed with mononucleosis. Which activity should the PN advise the adolescent to avoid?

Correct answer: C

Rationale: Contact sports should be avoided in mononucleosis due to the risk of spleen rupture, which is a serious complication of the disease. The spleen can enlarge in mononucleosis, making it more susceptible to injury from contact sports, potentially leading to a life-threatening situation if rupture occurs.

5. The healthcare professional is developing a program to educate parents on the importance of immunizations. Which topic should be prioritized?

Correct answer: A

Rationale: Prioritizing the benefits of immunizations is crucial in helping parents comprehend the significance of vaccines in safeguarding their children against preventable diseases. Understanding the positive impact of immunizations can alleviate concerns and misconceptions that parents may have, ultimately encouraging them to make informed decisions regarding their children's health. Discussing potential side effects (choice B) is important but should come after highlighting the benefits to avoid instilling unnecessary fear. While the immunization schedule (choice C) is essential information, it may be overwhelming if presented as the initial focus. Comforting children during vaccinations (choice D) is valuable but secondary to ensuring parents understand the benefits of immunizations.

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