For the past six hours, a postoperative male client has refused pain medication because he believed that he could "tough it out." When an opioid analgesic is administered, the client has difficulty obtaining a satisfactory level of comfort.

Which action is best for the practical nurse (PN) to use in assisting this client to deal with his pain?

The correct answer is Choice C. Following abdominal surgery, a client experiences wound evisceration.

Choice A rationale:

Cellulitis developing around a foot wound in a client with diabetes mellitus (DM) is a concerning situation, but it does not require the most immediate intervention compared to wound evisceration. Cellulitis is a bacterial skin infection that can usually be treated with antibiotics, while wound evisceration is a surgical emergency.

Choice B rationale:

Following suture removal from a stab wound, wound dehiscence is a serious complication, but it is not as immediately life-threatening as wound evisceration. Wound dehiscence is the separation of the wound edges after closure, and while it requires prompt attention, it does not involve the protrusion of organs from the wound.

Choice C rationale:

Wound evisceration, the protrusion of organs through a surgical incision, is a life-threatening complication that requires immediate intervention. The practical nurse should cover the exposed organs with a sterile, moist dressing and seek immediate medical assistance to prevent infection and further complications.

Choice D rationale:

For a client with a stage 4 sacral pressure ulcer developing purulent drainage is a concern, but it is not as immediately critical as wound evisceration. Proper wound care and infection management are essential, but the urgency level is lower compared to wound evisceration.

The correct answer is choicec. Ask the parents to explain what they understand about the child’s diagnosis.

Choice A rationale:

While it is important to support the parents’ decisions, this choice does not address the need for accurate information and understanding about the condition and its management.

Choice B rationale:

Hypospadias does not typically resolve on its own, and delaying surgery can lead to complications such as difficulty with urination and sexual function later in life.

Choice C rationale:

Asking the parents to explain what they understand about the child’s diagnosis ensures that they have accurate information and can make an informed decision about the timing of surgery.This approach also allows the nurse to correct any misconceptions and provide necessary education.

Choice D rationale:

Delaying surgery for hypospadias can lead to complications, including issues with urination and sexual function.It is important to address these potential risks with the parents.