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 ["40"]

Explanation

The client’s 0730 finger stick glucose is 271 mg/dL. According to the sliding scale parameters, the client should receive:

Step 1: Determine the amount of insulin aspart based on the sliding scale. Since the glucose level is 271 mg/dL, which falls in the range of 270 to 300 mg/dL, the client should receive 15 units of insulin aspart.

Step 2: Add the amount of NPH insulin to the amount of insulin aspart. The client has a prescription for NPH insulin 25 units before breakfast. So, the total amount of insulin this client should receive is 25 units (NPH insulin) + 15 units (insulin aspart) = 40 units.

So, the total amount of insulin this client should receive is40 units.

A. Temperature. B. Pain scale. C. Bowel sounds. D. Blood pressure.

Correct Answer is A

Explanation

The correct answer is Choice A. Temperature. Choice A rationale:

The practical nurse (PN) should complete the data collection for temperature first. A large amount of sanguineous drainage on the abdominal incision dressing could indicate possible infection or a change in the client's condition. Elevated temperature may be an early sign of infection, which requires immediate attention and appropriate intervention.

Choice B rationale:

Assessing the pain scale is important, but it can be addressed after completing the data collection for temperature. Pain assessment is essential for providing appropriate pain management, but it is not the most urgent concern when there is a significant amount of drainage from the incision site.

Choice C rationale:

Checking bowel sounds is relevant in postoperative care, but it is not the priority at this moment. Abdominal incision drainage takes precedence as it may indicate a more critical issue that requires immediate attention.

Choice D rationale:

Monitoring blood pressure is essential, but it is not the most immediate concern in this scenario. A large amount of sanguineous drainage from the abdominal incision takes precedence over blood pressure monitoring at this time.

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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

Correct Answer is ["40"]

Explanation

When monitoring a client's abdominal incision, the practical nurse (PN) observes a large amount of sanguineous drainage on the dressing. Which client data collection should the PN complete first?

Correct Answer is A

Explanation

The practical nurse (PN) observes a client's initial postoperative dressing and drain as seen in the picture. Which follow-up actions should the PN implement? (Select all that apply.).

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The practical nurse (PN) receives a report of a stable client who experienced partial burn thickness over 30% burns body surface area (BSA) 3 days ago. Which complication is most important for the PN to anticipate?

A client is scheduled to receive a sublingual tablet and has difficulty swallowing tablets. Which is the best nursing action?

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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?