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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Electrolytes.
Choice A rationale: The white blood cell count (WBC) is typically reviewed for signs of infection or inflammation, but it is not directly related to numbness and tingling.
Choice B rationale: Hematocrit levels assess the proportion of red blood cells in the blood, which are not commonly associated with numbness and tingling.
Choice C rationale: Albumin and protein levels are important for nutritional status and overall health but are not directly associated with numbness and tingling.
Choice D rationale: Electrolytes are crucial for nerve function and muscle contractions. Abnormal levels of electrolytes (such as calcium, potassium, or sodium) can lead to symptoms like numbness and tingling in the extremities.
Correct Answer is A
Explanation
A thready pulse is a weak and rapid pulse that is easily obliterated by light pressure. It indicates poor blood flow and perfusion and may be caused by conditions such as shock, dehydration, or hemorrhage.
The other options are not correct because:
B. A missing pulse is a pulse that is absent or cannot be detected, even with firm pressure. It indicates a complete blockage of blood flow, and may be caused by conditions such as arterial occlusion, embolism, or trauma.
C. Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.
D. Pulse skips beats is a documentation of an irregular pulse rhythm, not a pulse volume. It indicates that the heart beats are unevenly spaced, and may be caused by conditions such as arrhythmia, stress, or caffeine intake.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today