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.

Answer and Explanation

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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Correct Answer is B

Explanation

This is the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer. Observing how the UAP obtains temperatures will help the PN identify any errors or problems with the technique, equipment, or documentation. The PN can then provide feedback and guidance to the UAP to ensure accurate and reliable temperature measurements.

A. The sliding scale insulin lispro order B. The type of insulin to be administered C. The insulin vial for color and clarity D. The dose of insulin drawn up in the syringe E. The expiration date on the insulin vial F. The history and physical with the diabetes diagnosis listed G. The insulin concentration H. The site for the insulin administration

Correct Answer is ["C","D","E","G"]

Explanation

The PN should double-check the following with a second nurse:

The dose of insulin drawn up in the syringe: Double-checking the dose of insulin is essential to ensure the correct amount is being administered to the client.
The insulin vial for color and clarity: Insulin should be clear and free of particles or discoloration. Checking the vial for any abnormalities ensures the integrity and quality of the insulin.
The expiration date on the insulin vial: Insulin should not be used beyond its expiration date. Verifying the expiration date helps ensure that the insulin is still effective and safe for administration.
The insulin concentration: Different concentrations of insulin are available, such as

U-100 and U-500. Double-checking the concentration ensures that the correct type of insulin is being administered.

It's important to note that the other options listed are not necessary for double-checking with a second nurse in this context:

The sliding scale insulin lispro order: Sliding scale insulin is typically used to adjust insulin doses based on blood glucose levels. However, in this case, the given dose of 2 units of insulin lispro may be a specific prescription for the client's diabetes management and not related to the acute appendicitis.
The type of insulin to be administered: The type of insulin, in this case, is specified as insulin lispro. Confirming the type of insulin is important, but it is not a part of the double-checking process since it is already specified.
The history and physical with the diabetes diagnosis listed: The client's medical history and diabetes diagnosis are important aspects of their overall care but are not directly related to double-checking the administration of insulin.
The site for insulin administration: The specific site for insulin administration may depend on the client's individual preference or medical condition, but it is not a part of the double-check process. The double-check is primarily focused on the accuracy of the medication itself.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using a tympanic thermometer. Which action should the PN take first?

Correct Answer is B

Explanation

Correct Answer is ["C","D","E","G"]

Explanation

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