The practical nurse (PN) views the mid-line episiotomy of a client who reports pain in her stitches. Which action should the PN take first?

Apply an ice pack for 20 minutes to the episiotomy.

Observe suture line for separation and hematoma formation.

Initiate daily warm sitz baths during onset of pain.

Check medication administration record for last PRN analgesic.

Answer and Explanation

The Correct Answer is B

A. Applying an ice pack can help manage pain and reduce swelling, but it is not the immediate priority. It is essential first to assess for complications that may require different interventions.
B. Observing the suture line for separation and hematoma formation is the first step in managing pain. Identifying possible complications like suture line issues or hematomas will guide the appropriate treatment.
C. Initiating warm sitz baths is beneficial for pain management and healing, but it should be done after assessing the episiotomy for potential complications. It is a supportive measure rather than an immediate assessment action.
D. Checking the medication administration record is relevant for managing pain but is secondary to assessing the condition of the episiotomy site. The first priority is to evaluate the site for any physical complications.

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Correct Answer is C

Explanation

A. Notifying the charge nurse is important but should come after confirming the accurate heart rate assessment.
B. Holding a prescribed morning dose of digoxin may be necessary if bradycardia is confirmed, but the first step is to accurately assess the heart rate.
C. Obtaining a full minute apical pulse assessment is the first step to verify the radial pulse rate reported by the UAP and ensure an accurate and comprehensive assessment of the client's heart rate.
D. Reviewing the client's baseline vital signs is useful but should follow a thorough and accurate assessment of the current heart rate.

A. Tell the client to see the good parts of life with two children who love the client. B. Provide the client with information about the Multiple Sclerosis Society. C. Allow the client to be alone by providing privacy to grieve. D. Sit quietly with the client and answer questions the client may ask.

Correct Answer is D

Explanation

A. Telling the client to focus on the positive aspects of life might seem dismissive of the client's current emotional state and concerns.
B. Providing information about support groups is helpful but should follow an initial supportive and empathetic response.
C. Allowing the client privacy may be necessary later, but initially, it is important to offer support and presence.
D. Sitting quietly with the client and answering any questions demonstrates empathy, support, and availability, helping the client process the new diagnosis and feel less isolated.

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The practical nurse (PN) views the mid-line episiotomy of a client who reports pain in her stitches. Which action should the PN take first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is D

Explanation

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