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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Missing the child every day is a normal part of the grieving process but does not indicate improvement in managing depression.
B. Drinking 4 to 6 bottles of beer each evening suggests the client may be using alcohol as a coping mechanism, indicating poor management of depression.
C. Expressing that drunk driving is inexcusable shows the client has a strong opinion on the matter, but it does not necessarily indicate improvement in the client’s emotional health.
D. Sleeping through the night often indicates an improvement in the client’s ability to rest and manage depressive symptoms, suggesting a positive response to treatment.
Correct Answer is A
Explanation
A. Instructing the UAP to lower the bed for safety is the correct action. The bed should be in a low position to prevent falls and ensure safety during client care activities.
B. Determining if the UAP would like assistance is not the most effective immediate action. The priority is to address the safety concern of the bed position rather than offering assistance.
C. Remaining in the room to supervise the UAP is less effective than directly addressing the safety issue. The bed should be in the proper position for safe client care.
D. Assuming care of the client immediately is not necessary unless there are additional concerns about the client's well-being. The primary action should be to correct the unsafe practice of the bed position.
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