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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The best action for the practical nurse (PN) to assist the client in dealing with his pain would be to guide the client through slow, rhythmic breathing.
Guiding the client through slow, rhythmic breathing techniques can help promote relaxation and reduce anxiety, which can indirectly contribute to pain relief. Deep breathing exercises can help the client focus on their breath and divert attention away from the pain, providing some relief and helping them cope with the discomfort. It is a non-pharmacological intervention that can be implemented immediately to help the client manage their pain.
The other options are less effective or not appropriate in this situation:
A. Dimming the lights in the room and closing the door may create a more calming environment, but it does not directly address the client's pain or provide them with effective pain relief.
B. Turning the television on to the client's favorite show may serve as a distraction, but it may not be sufficient to alleviate the client's pain.
D. Obtaining a prescription for a higher dose of pain medication should only be considered after evaluating the client's current pain management regimen and assessing their response to the current medication. It is not the immediate best action to take without further assessment and consideration of other non-pharmacological interventions.
Correct Answer is C
Explanation
This question is related to the responsibilities and scope of practice of a practical nurse (PN) and a medication aide. A medication aide is a certified nursing assistant (CNA) who is responsible for administering daily medication to patients under the supervision of a licensed nurse, such as a PN or a registered nurse (RN). A PN is a licensed nurse who can provide routine care, observe patients’ health, assist doctors and RNs, and communicate instructions to patients regarding medication, home-based care, and preventative lifestyle changes.
Based on this information, the best action that the PN should take in this situation is c. Assign the remainder of medication administration to another PN who is performing treatments. This is because it would ensure that the medication administration is completed by another licensed nurse who has the knowledge, skills, and authority to do so. The PN who is performing treatments may have some spare time or be able to rearrange their schedule to accommodate the additional task. The PN should also communicate with the other PN and the medication aide about the situation and document the change of assignment in the patients’ records.
Option a is not a good choice, because it would be unfair and unethical to deny the medication aide’s request to leave if they are sick. The medication aide’s health and well-being are also important, and forcing them to stay and work could compromise their safety and the quality of care they provide to the patients.
Option b is not a good choice, because it would be outside the scope of practice of the UAPs to give medications to the patients. UAPs are not trained or certified to administer medications, and doing so could pose serious risks to the patients’ health and safety. The PN would also be liable for any errors or adverse outcomes that may result from the UAPs’ actions.
Option d is not a good choice, because it would not solve the problem of the medication administration being incomplete. Documenting why the medications were not given is important, but it is not enough to ensure that the patients receive their prescribed drugs and treatments. The PN still has the responsibility to find a way to complete the medication administration or delegate it to another qualified and available person.
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