When caring for postoperative clients, which situation requires the most immediate intervention by the practical nurse (PN)?

A client with diabetes mellitus (DM) develops cellulitis around a foot wound.

Following suture removal from a client's stab wound, the wound dehisces.

Following abdominal surgery, a client experiences wound evisceration.

A client with a stage 4 sacral pressure ulcer develops purulent drainage.

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is ["A","C","E"]

Explanation

Choice A rationale:

Obtaining a post-voided residual (PVR) volume is a non-invasive procedure that can be safely delegated to the unlicensed assistive personnel (UAP) to measure the amount of urine left in the bladder after urination.

Choice B rationale:

Teaching the client with fluid restrictions how to measure urine output requires specialized knowledge and is best performed by the practical nurse (PN).

Choice C rationale:

Emptying the bedside drainage unit for a client with an indwelling urinary catheter is a task that can be delegated to the UAP as it involves routine drainage and does not require advanced nursing skills.

Choice D rationale:

Irrigating an indwelling urinary catheter for a client with bladder suspension is a sterile procedure that requires nursing expertise, so it should not be assigned to the unlicensed assistive personnel.

Choice E rationale:

Transporting a urine culture sample to the laboratory is a non-complex task that can be safely delegated to the UAP to ensure timely and efficient delivery.

A. Periodic nausea and vomiting. B. Decreased deep tendon reﬂexes. C. Platelet count 135,000/mm3 or 135 x 10^9/L D. Blood urea nitrogen 75 mg/dL or 12.9 mmol/L

Correct Answer is D

Explanation

A high blood urea nitrogen (BUN) level indicates impaired renal function, which can be caused by dehydration, infection, or nephrotoxic drugs. Chemotherapy can damage the kidneys and increase the risk of renal failure. The PN should report this finding to the charge nurse, as it may require ﬂuid replacement, dose adjustment, or discontinuation of the chemotherapy.

The other options are not correct because:

A. Periodic nausea and vomiting are common side eﬀects of chemotherapy that can be managed with antiemetics, hydration, and dietary modifications. They are not as urgent as a high BUN level.

B. Decreased deep tendon reﬂexes may indicate hypocalcemia, hypomagnesemia, or peripheral neuropathy, which can be caused by chemotherapy or other factors. They are not as urgent as a high BUN level.

C. A platelet count of 135,000/mm3 or 135 x 10^9/L is slightly below the normal range, but not significantly low. Chemotherapy can cause thrombocytopenia, which increases the risk of bleeding. The PN should monitor the client for signs of bleeding, but this finding is not as urgent as a high BUN level.

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When caring for postoperative clients, which situation requires the most immediate intervention by the practical nurse (PN)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.).

Correct Answer is ["A","C","E"]

Explanation

Correct Answer is D

Explanation

Which statement by an older female client who lost her spouse two years ago should indicate to the practical nurse (PN) that the client may need bereavement counseling?

The practical nurse (PN) plans to screen only high-risk children for scoliosis. Which group of children should the PN screen?

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

The practical nurse (PN) is reviewing a client's recent ophthalmic screening test results. Findings of optic neuropathy, loss of peripheral vision, and increased intraocular pressure are consistent with which medical condition?

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A male client who has just been told he has cancer asks the practical nurse (PN) to leave his room so he can be alone. Which action should the PN implement?

Which finding should the practical nurse (PN) instruct the postpartum client to report to the charge nurse?