The practical nurse (PN) is planning care for a client who has a fourth degree midline laceration that occurred during vaginal delivery of an 8 lb 10 oz (3.91 kg) infant. Which intervention has the highest priority for this client?
Recommend using a prescribed analgesic perineal spray.
Administer a prescribed stool softener.
Give a prescribed PRN sleep medications.
Encourage breastfeeding to promote uterine involution.
The Correct Answer is B
A. Recommend analgesic perineal spray: Helps pain but not top priority for preventing complications.
B. Administer stool softener: Prevents strain that could disrupt complex repair.
C. Give PRN sleep medication: Comfort measure but low priority.
D. Encourage breastfeeding: Helps uterine involution but unrelated to laceration healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A. Instruct team members to ignore the client's hallucinations: Incorrect; ignoring can increase anxiety; therapeutic acknowledgment is needed.
B. Acknowledge that the client's perception is not real to others: Validates feelings without reinforcing hallucinations, helps maintain reality orientation.
C. Instruct the client to stop scaring the other clients: Confrontational and non-therapeutic.
D. Offer support and reassure the client that he is in a safe place: Reduces anxiety and builds trust.
E. Use simple commands in a calm, soothing voice: Helps with comprehension and reduces agitation.
F. Restrict the client to his room and apply soft wrist restraints: Only used if there is immediate danger to self/others; not indicated here.
Correct Answer is C
Explanation
A. A frail older adult who needs help to ambulate to the dining room for a meal:
This is important but not as urgent as toileting after a diuretic.
B. An older adult with a colostomy who needs the bag emptied:
This is routine and can wait a short time.
C. An older adult who received a diuretic 30 minutes ago and is asking for a bedpan:
Urgent to prevent incontinence and skin breakdown; needs immediate attention.
D. An older adult who needs mouth care for a dry mouth:
This is comfort care and can be delayed safely.
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