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

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:

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.
Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.
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.

A. The size of my breasts is of no concern to you. B. That language is not allowed. C. Do you really think so? D. If you talk like that again, I will tell your parents.

Correct Answer is B

Explanation

This is the best response for the PN to provide because it sets a clear and firm boundary for the adolescent and discourages inappropriate or sexual comments. The PN should also redirect the adolescent's atention to another topic or activity and document the incident.

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

Correct Answer is A

Explanation

A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), "Wow! You have big breasts." Which response is best for the PN to provide?

Correct Answer is B

Explanation

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?

During a home visit, the home health practical nurse (PN) observes an older client attempting to ambulate to the bathroom and notes that the client is unsteady and holds on to furniture while refusing any assistance. Which action should the PN implement?

The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) in charge of the unit take?

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?

In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the practical nurse (PN) to include in the assessment of this client?

The practical nurse (PN) is assisting with the preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible. Which action should the PN implement?

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?