The nurse is planning care for a client who has a fourth-degree midline laceration that occurred during vaginal delivery of an 8-pound 10-ounce (3674 grams) infant.
Which intervention has the highest priority for this client?
Administer prescribed PRN sleep medications.
Encourage use of prescribed analgesic perineal sprays.
Administer prescribed stool softener.
Encourage breastfeeding to promote uterine involution.
The Correct Answer is C
The correct answer is choice c. Administer prescribed stool softener.
Choice A rationale:
Administering prescribed PRN sleep medications can help the client rest, but it is not the highest priority. Managing pain and preventing complications from the laceration are more critical.
Choice B rationale:
Encouraging the use of prescribed analgesic perineal sprays can help manage pain and promote healing, but it is not as crucial as preventing constipation, which can cause significant discomfort and complications.
Choice C rationale:
Administering prescribed stool softeners is the highest priority because a fourth-degree laceration involves the anal sphincter and rectal mucosa. Preventing constipation is essential to avoid straining during bowel movements, which can cause pain and disrupt the healing process.
Choice D rationale:
Encouraging breastfeeding to promote uterine involution is important for postpartum recovery, but it is not directly related to the care of a fourth-degree laceration. Managing pain and preventing complications from the laceration take precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
This statement is incorrect. Major Depressive Disorder (MDD) is typically more severe than dysthymia and is characterized by recurrent episodes of severe depression lasting at least two weeks.
Choice B rationale:
This statement is incorrect. Dysthymia is not characterized by alternating episodes of mania and depression. It is a chronic, low-grade depressive disorder.
Choice C rationale:
This statement is incorrect. Dysthymia can impair social and occupational functioning, similar to MDD. Both conditions can have a significant impact on a person's daily life.
Choice D rationale:
This statement is accurate. Dysthymia is a chronic depressive disorder that lasts for at least two years but is generally less severe than MDD. It is characterized by persistent, milder symptoms of depression.
Correct Answer is A
Explanation
The correct answer and explanation are:
A - Ask the client to describe what happened. Correct
This is the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.
Asking the client to describe what happened shows empathy, respect, and active listening, and allows the PN to gather more information and validate the client's feelings and concerns. The PN should also apologize for the delay, assess the client's pain level and needs, and provide appropriate interventions and support.
B - Inform the charge nurse of the situation.
This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.
Informing the charge nurse of the situation may be necessary, but it should be done after addressing the client's immediate needs and concerns. The PN should not ignore or avoid the client, but should communicate with him and try to resolve the issue.
C - Complete a client adverse incident report.
This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.
Completing a client adverse incident report may be required, but it should be done after addressing the client's immediate needs and concerns. The PN should not prioritize documentation over care, but should provide timely and effective pain management and support to the client.
D - Call the agency-based client advocate.
This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times. Calling the agency-based client advocate may be helpful, but it should be done after addressing the client's immediate needs and concerns.
The PN should not delegate or defer responsibility for care, but should communicate with the client and try to resolve the issue. The PN should also respect the client's right to choose whether or not to involve an advocate in his care.
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