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 A

Explanation

A. A preschooler who had an emergency appendectomy should be checked first. Children are at higher risk for complications due to their size and the stress of emergency surgery, so close monitoring is essential.
B. An adult with osteomyelitis post-surgery is important to monitor but is generally at lower immediate risk compared to a young child following emergency surgery.
C. A post-menopausal client with breast cancer who had a lumpectomy is also a priority, but the immediate postoperative period for a child in emergency surgery takes precedence.
D. An adolescent with type 1 diabetes who had cholecystectomy requires careful monitoring, but the child’s higher risk in the immediate postoperative phase makes them the priority.

A. Take the child's pulse B. Place a cervical collar on the client C. Call child protective services D. Start a peripheral IV line E. Look for any open wounds F. Determine if the child's airway is clear

Correct Answer is A, F, E

Explanation

A. Take the child's pulse

Assessing the pulse is crucial to determine if the child has a heartbeat and to evaluate the effectiveness of CPR. This helps to determine the current cardiovascular status of the child and the urgency of further resuscitation efforts.

F. Determine if the child's airway is clear

Ensuring a clear airway is a priority in any emergency situation. A blocked airway can prevent effective ventilation and oxygenation, which is critical for a child who has experienced a near-drowning incident.

D. Start a peripheral IV line

Starting a peripheral IV line is important for administering fluids and medications that may be necessary for resuscitation and stabilization. It allows for rapid access to the child's circulatory system for necessary interventions.

E. Look for any open wounds

Checking for open wounds is necessary to identify any immediate sources of bleeding or potential infections that need to be addressed. It is part of a thorough initial assessment to ensure comprehensive care for the child.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is planning evening shift rounds for a group of postoperative clients who all had surgery earlier that day. Which client should the PN check first?

Correct Answer is A

Explanation

Exhibits Review H and P and nurse's note. Which are the first four actions that the practical nurse (PN) should do?

Correct Answer is A, F, E

Explanation

Exhibits The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.

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The practical nurse (PN) plans to use distraction techniques while a client undergoes a brief painful procedure. Which action should the PN implement during the procedure?

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