The practical nurse (PN) views the mid-line episiotomy of a client who reports pain in her stitches. Which action should the PN take first?
Apply an ice pack for 20 minutes to the episiotomy.
Observe suture line for separation and hematoma formation.
Initiate daily warm sitz baths during onset of pain.
Check medication administration record for last PRN analgesic.
The Correct Answer is B
A. Applying an ice pack can help manage pain and reduce swelling, but it is not the immediate priority. It is essential first to assess for complications that may require different interventions.
B. Observing the suture line for separation and hematoma formation is the first step in managing pain. Identifying possible complications like suture line issues or hematomas will guide the appropriate treatment.
C. Initiating warm sitz baths is beneficial for pain management and healing, but it should be done after assessing the episiotomy for potential complications. It is a supportive measure rather than an immediate assessment action.
D. Checking the medication administration record is relevant for managing pain but is secondary to assessing the condition of the episiotomy site. The first priority is to evaluate the site for any physical complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Understanding what the voices are saying is the most important initial step in assessing auditory hallucinations. This information helps the PN gauge the content of the hallucinations, which is crucial for developing a treatment plan and determining the level of risk to the client or others.
B. While knowing when the voices are most disturbing provides useful information for managing symptoms, it is less critical than understanding the content of the hallucinations for developing an initial treatment plan.
C. Assessing how the client copes with the voices is important for ongoing management but comes after understanding what the voices are saying. Coping strategies can be developed based on the nature of the hallucinations.
D. Determining which medication works best is not an immediate priority during the initial assessment. Medication effectiveness will be evaluated over time rather than being a primary focus during the first report of hallucinations.
Correct Answer is ["A","D","E"]
Explanation
A. Oatmeal is a good choice for breakfast.
Oatmeal is a good source of iron and can be part of a vegetarian diet. It is a suitable option for increasing iron intake while adhering to vegetarian dietary restrictions.
B. Eat red meat just until the anemia is resolved.
This option is not suitable for a vegetarian client. Red meat is a source of heme iron, but it conflicts with the client’s dietary preferences and does not align with a vegetarian diet.
C. Take two prenatal vitamins with iron daily.
Doubling the dose of prenatal vitamins is not recommended without specific advice from a healthcare provider. The prescribed dosage should be followed, and dietary changes should be the focus.
D. Add lentils and black beans to soups.
Lentils and black beans are excellent sources of non-heme iron, which fits well within a vegetarian diet. Including these foods in meals can help boost iron levels effectively.
E. Increase green leafy vegetables in the diet.
Green leafy vegetables are high in non-heme iron and are suitable for vegetarians. Increasing their consumption supports iron intake and helps manage anemia.
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