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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Coffee-ground secretions draining via nasogastric tube suction.
Choice A rationale:
Oral ice chips eaten 30 minutes after vomiting postoperatively could be considered normal in some cases. However, this finding may not require immediate reporting to the RN unless
other concerning symptoms are present. Choice B rationale:
The inability to void 4 hours after discontinuing an indwelling catheter is not an immediate concern. It's not uncommon for some clients to experience difficulty urinating initially after catheter removal. The client should be closely monitored, and the RN should be informed if the situation persists or worsens.
Choice C rationale:
This is the correct answer because coffee-ground secretions draining via nasogastric tube suction can indicate bleeding in the gastrointestinal tract, potentially from the stomach or esophagus. This finding requires immediate attention as it could be a sign of a serious condition and may require urgent intervention.
Choice D rationale:
Ineffective pain management reported while using morphine PCA is a concern but may not be as critical as the coffee-ground secretions. The PN should still report this finding to the RN for appropriate assessment and possible adjustment of pain management, but it may not warrant immediate reporting.
Correct Answer is B
Explanation
The correct answer is choice B: Thinning of the skin with loss of elasticity.
Choice A rationale:
While a decreased ability to communicate can be a significant challenge in elderly clients, it is not the primary physical characteristic of aging that contributes to the risk of pressure ulcers. Pressure ulcers develop due to prolonged pressure on specific areas of the skin, leading to reduced blood flow and tissue damage.
Choice B rationale:
Thinning of the skin with loss of elasticity is a critical physical characteristic of aging that contributes to the risk of pressure ulcers. As the skin becomes thinner and less elastic with age, it becomes more susceptible to injury from pressure and shear forces, increasing the likelihood of developing pressure ulcers.
Choice C rationale:
A 16 percent increase in overall body fat does not directly contribute to the risk of pressure ulcers. While changes in body composition occur with aging, the primary risk factors for pressure ulcers are related to skin integrity and mobility, not body fat percentage.
Choice D rationale:
Calcium loss in the bones (osteoporosis) is not the main contributing factor to pressure ulcers. Osteoporosis primarily affects bone density and strength but does not directly influence the development of pressure ulcers.
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