A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority?
Administer a PRN dose of acetaminophen.
Encourage the client to drink fluids.
Report the findings to the charge nurse.
Monitor the client's serum lipid levels.
The Correct Answer is C
This is the priority action by the practical nurse (PN) because it can help identify and prevent a potential adverse reaction to the medication. A client who is reaching saturation with medication means that the client has reached the maximum level of medication in the blood that can produce the desired therapeutic effect. However, this also means that the client is at a higher risk of developing toxicity or side effects from the medication.
The PN should report the findings of muscle soreness, fatigue, and warm skin to the charge nurse, as these may indicate signs of inflammation, infection, or allergic reaction to the medication. The PN should also monitor the client's vital signs, oxygen saturation, and laboratory values, and document the findings. The charge nurse should notify the health care provider and adjust the medication dosage or regimen as ordered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The client's statements suggest significant distress, feelings of being a burden, and a sense of hopelessness related to their obsessive-compulsive disorder (OCD). Given the severity of these statements, it is crucial for the PN to assess the client's risk of suicide or self-harm. Asking directly about suicidal thoughts or considering suicide as an option allows the PN to evaluate the immediate safety of the client and take appropriate actions to ensure their well-being.
While the other options may also provide relevant information, they are not as critical as assessing the client's risk of suicide.
B. Questioning about which rituals are most often used to reduce anxiety can help gather information about the client's specific OCD symptoms and coping mechanisms.
C. Determining what makes the client think people are laughing can provide insight into their perception of how others view them, but it may not address the immediate risk of harm.
D. Asking about the impact of obsessions and compulsions on sleep can help assess the client's overall functioning, but it does not address the immediate risk of suicide.
Correct Answer is D
Explanation
A. C-reactive protein level:
C-reactive protein (CRP) is a marker of inflammation but does not specifically identify the causative organism of an infection. While elevated CRP can suggest infection or inflammation, it doesn't provide the necessary information for treatment.
B. Serum blood glucose (BG) level:
Serum blood glucose levels are important to monitor in diabetic patients because high glucose levels can impair healing and increase the risk of infection. However, it does not directly help identify the causative organism in this situation.
C. Serum albumin:
Serum albumin reflects nutritional status and can indicate malnutrition or poor wound healing. While it may be relevant for healing, it is not the most immediate test to evaluate for infection.
D. Culture for sensitive organisms:
Given the red, swollen wound with drainage and foul odor, a wound culture is the most appropriate first step to identify the specific infectious organism. This will guide the healthcare provider in selecting the most appropriate antibiotic treatment.
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