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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Re-lubricating the tubing and re-inserting it is unnecessary if the enema solution is not infusing; the primary issue is likely related to the tubing's position or the height of the container.
B. Inserting the tubing an additional three inches into the rectum ensures that it is positioned correctly for the solution to flow. If the tubing is not inserted far enough, the solution may not enter the rectum.
C. Raising the saline container higher is not needed since it is already six inches above the client’s body. The problem is more likely related to the tubing’s depth rather than the height of the container.
D. Instructing the client to take deep breaths does not affect the infusion of the enema solution. The solution's flow is influenced by the mechanics of the enema administration, not by the client’s breathing.

A. Explain that the form identifies his personal health care wishes for any future event. B. Acknowledge the client's concerns and notify the healthcare provider of the client's wishes. C. Ask a family member to describe the client's stated wishes regarding end-of-life care. D. Document his refusal in his electronic medical record using his exact words.

Correct Answer is A

Explanation

A. Explaining that the advanced directives form helps identify personal health care wishes for any future health event is crucial because it clarifies the importance of the form in planning for future health care decisions, even if the client is not currently ill.
B. Acknowledging the client’s concerns and notifying the healthcare provider is less immediate and does not directly address the client's understanding of the advanced directives form.
C. Asking a family member about the client's wishes is unnecessary since the client has communicated his own wishes and concerns, and the focus should be on informing the client about the form.
D. Documenting the client’s refusal is important but secondary to educating the client on the purpose and importance of advanced directives.

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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?

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Naxlex Comprehensive Predictor Exams

When administering a saline enema, the practical nurse (PN) inserts the enema tubing three inches into the client's rectum, and elevates the container six inches above the client's body. When the clamp is opened, the solution does not infuse. Which action should the PN take?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

Exhibits Drag from statement options to complete the sentence. To assess outcomes, the practical nurse (PN) should consider information reported by the client and caregiver and focus on evaluating the client's dropdown and dropdown

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