Which intervention is the most important for the practical nurse (PN) to implement when applying an ice pack to a client?

Wrap the bag in place for comfort.

Secure a protective cover over the bag.

Give directions to leave the pack in place.

Fill the ice pack with crushed ice

Answer and Explanation

The Correct Answer is B

The most important intervention for the practical nurse (PN) to implement when applying an ice pack to a client is to secure a protective cover over the bag. This is essential to protect the client's skin from direct contact with the ice pack, which can cause tissue damage, frostbite, or discomfort.
Securing a protective cover, such as a thin cloth or towel, between the ice pack and the client's skin helps to create a barrier and prevent excessive cold exposure. It allows for the therapeutic benefits of the ice pack, such as reducing swelling and pain, while minimizing the risk of skin damage.
Incorrect:

A. While wrapping the bag in place for comfort is important, it is not the most critical intervention compared to ensuring the protection of the client's skin.
C. Giving directions to leave the pack in place is a general instruction for the client to follow the prescribed treatment, but it does not specifically address the importance of using a protective cover.
D. The type of ice used, whether crushed or cubed, may vary based on availability and preference, but it does not take precedence over the need to protect the client's skin with a cover.

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Correct Answer is B

Explanation

Monitoring the client's vital signs, including temperature, heart rate, respiratory rate, and blood pressure, is crucial to assess for any signs of infection or complications following surgery.
A. While fluid volume intake and output are important to monitor for overall hydration status, it is not the most immediate concern after reinforcing the dressing.
C. Similarly, assessing the volume of peripheral pulses is important to evaluate peripheral perfusion, but it may not be the highest priority at this time.
D. Incisional pain scale rating is important to assess the client's comfort and pain level, but it should be done after ensuring the security of the surgical dressing.

A. A primigravida whose perineal pain has worsened one hour after being medicated. B. A primigravida who passed a small clot when she sat up on the edge of the bed. C. A multigravida whose peri-pad is 1⁄2 saturated with lochia rubra after one hour. D. A multigravida complaining of strong afterbirth pains when breastfeeding.

Correct Answer is A

Explanation

Worsening perineal pain after medication could indicate inadequate pain relief or a potential complication such as infection or hematoma. It is important to reassess the client to determine the cause of the increased pain and take appropriate action before transferring to the postpartum unit.
The other scenarios described in the options may also require attention, but they do not indicate an immediate need for reassessment before transfer:
B. A primigravida who passed a small clot when she sat up on the edge of the bed: Passing small clots is a normal part of the postpartum period, and it may not necessarily require immediate reassessment. However, the PN should monitor for any excessive or large clots and report any concerning findings.
C. A multigravida whose peri-pad is 1⁄2 saturated with lochia rubra after one hour: Lochia rubra is the normal discharge following childbirth, and some saturation of the peri-pad is expected.
However, the PN should continue to monitor the amount and consistency of the lochia and report any significant changes.
D. A multigravida complaining of strong afterbirth pains when breastfeeding: Afterbirth pains, also known as uterine cramps, are common during breastfeeding as the uterus contracts. While discomfort is expected, strong afterbirth pains should be assessed for severity and managed appropriately. The PN should provide comfort measures and assess if the pain is within the expected range or if it requires further evaluation.

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Which intervention is the most important for the practical nurse (PN) to implement when applying an ice pack to a client?

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

Exhibits Drag from word choices to complete the sentence. Based on the laboratory data, the client has related to

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