The practical nurse (PN) is caring for a client with a new prescription for fluticasone furoate nasal spray, a glucocorticoid prescribed for the client's nasal allergy symptoms.

In reinforcing instructions about self-administration of the nasal spray, the PN should emphasize the need for the client to take which action before self-administration?

The correct answer is choice D. Apply a pain scale to describe intensity.

Choice A rationale:

Asking about elements of the pain experience is important for a comprehensive pain assessment, but it is not the most critical aspect immediately after administering an analgesic. This step is more relevant during the initial assessment to understand the nature and characteristics of the pain.

Choice B rationale:

Questioning the client about precipitating factors can help identify what triggers the pain, which is useful for long-term pain management strategies. However, this is not the primary focus after giving an analgesic, as the immediate goal is to evaluate the effectiveness of the pain relief.

Choice C rationale:

Locating where in the body the pain occurs is essential for diagnosing and understanding the pain’s origin. However, after administering an analgesic, the priority is to assess the change in pain intensity rather than its location.

Choice D rationale:

Applying a pain scale to describe intensity is crucial after giving an analgesic because it provides a quantifiable measure of the pain relief achieved. This helps in determining the effectiveness of the medication and guides further pain management interventions.

By focusing on the pain intensity using a standardized pain scale, the practical nurse can objectively evaluate the patient’s response to the analgesic and make informed decisions about any additional pain management needs.

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.