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 C

Explanation

Choice A rationale:

Offering a high protein diet may not be appropriate for a client with hepatic failure. High protein intake can lead to the accumulation of ammonia in the bloodstream, worsening hepatic encephalopathy. Therefore, this choice is not the best intervention for the client.

Choice B rationale:

Performing range of motion exercises is important for clients with hepatic failure to prevent complications related to immobility. However, it does not directly address the client's elevated pulse rate and changes in mental status.

Choice C rationale:

Weighing the client every morning is essential in monitoring fluid status and identifying signs of fluid retention or dehydration, which are common in hepatic failure. Changes in weight can help detect early signs of worsening hepatic function.

Choice D rationale:

Providing only distilled water may not be appropriate for a client with hepatic failure. While it is essential to monitor fluid intake, restricting all fluids to only distilled water could lead to electrolyte imbalances and further complications. Monitoring overall fluid intake and type is important for these clients.

A. Oﬀer the client a prescribed sleep medication. B. Reposition the client and provide a back rub. C. Administer an as-needed (PRN) prescription for pain. D. Provide a cup of hot chocolate at bedtime.

Correct Answer is B

Explanation

This is the best initial intervention for the PN to implement because it promotes comfort, relaxation, and circulation for the client. A back rub can also reduce anxiety and muscle tension, which can interfere with sleep. The PN should use non-pharmacological methods to facilitate sleep before resorting to medication.

A. Oﬀering the client a prescribed sleep medication is not the best initial intervention because it may have side eﬀects or interactions with other drugs. The PN should assess the client's need for medication and use it as a last resort.

C. Administering an as-needed (PRN) prescription for pain is not the best initial intervention because it may not address the cause of the client's difficulty in sleeping. The PN should assess the client's pain level and use other methods to relieve pain before giving medication.

D. Providing a cup of hot chocolate at bedtime is not the best initial intervention because it may contain caﬀeine, which can stimulate the central nervous system and keep the client awake. The PN should avoid giving caﬀeinated beverages to the client before bedtime.

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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

A client is being treated for hepatic failure. On examination, the client has an elevated pulse rate and exhibited changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?

Correct Answer is C

Explanation

A client who had orthopedic surgery three days ago verbalizes difficulty in sleeping. Which initial intervention is best for the practical nurse (PN) to implement?

Correct Answer is B

Explanation

The practical nurse (PN) finds a postoperative client lying in bed with an unsecured surgical dressing as seen in the picture. After reinforcing the dressing, which follow-up assessment is most important for the PN to implement?

The practical nurse (PN) reviews the history of an older adult who is newly admitted to a long term care facility. Which factor in the resident's history should the PN consider the most likely to increase the client's risk for falls?

The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

During a clinic visit, a mother tells the practical nurse (PN) that she keeps her 2-year-old child in a playpen so he will not get dirty. Which rationale should the PN use in responding to this parent?

When caring for a child with sickle cell disease, the practical nurse (PN) expects that the child will most likely describe which symptom when experiencing a sickle cell crisis?

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?