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 D
Explanation
- A playpen is a portable enclosure that provides a confined space for a child to play in. It can be useful for keeping a child safe and supervised when the caregiver is busy or needs a break, but it should not be used as a substitute for active play or interaction with the caregiver or others.
- A 2-year-old child is in the developmental stage of toddlerhood, which is characterized by rapid physical, cognitive, social, and emotional growth. Toddlers are curious and eager to learn about the world around them, and they need opportunities to explore, experiment, and manipulate objects and materials. They also need stimulation, guidance, and feedback from their caregivers and peers to develop their language, problem-solving, and social skills.
- Keeping a 2-year-old child in a playpen for long periods of time or to prevent them from getting dirty can have negative effects on their development and well-being. It can limit their physical activity, creativity, and independence, and it can cause boredom, frustration, or resentment . It can also interfere with their attachment and bonding with their caregiver, as well as their self-esteem and self-image.
- Therefore, the practical nurse (PN) should use the statement "Children need time to actively explore their environment" in responding to this concern about using a playpen. This statement reflects the developmental needs and rights of the child, and it encourages the caregiver to provide a more stimulating and supportive environment for the child. It also implies that getting dirty is not a problem, but rather a natural and healthy part of play and learning.
- Therefore, option D is the correct answer, while options A, B, and C are incorrect. Option A is incorrect because it is judgmental and may offend or discourage the caregiver.
Correct Answer is A
Explanation
Edema, particularly if it is new or worsening, can be an indicator of preeclampsia, a potentially serious condition characterized by high blood pressure and organ dysfunction. Monitoring the client's blood pressure is crucial in assessing for signs of preeclampsia and determining the appropriate course of action.
B. Due date: The due date is an important piece of information for monitoring the progress of the pregnancy, but it is not directly relevant to the client's presenting symptom of edema. The focus should be on assessing for potential complications associated with edema, such as preeclampsia.
C. Fundal height: Fundal height is a measurement used to estimate fetal growth and position. While it is an important parameter to monitor during prenatal visits, it is not directly related to the client's edema. The priority in this situation is to assess for signs of preeclampsia or other complications, which may require assessing the blood pressure.
D. Gravida and parity: Gravida refers to the total number of pregnancies a woman has had, while parity refers to the number of pregnancies that have reached viability (20 weeks or more). While these pieces of information provide a background understanding of the client's obstetric history, they do not provide immediate insight into the current issue of edema. Assessing the blood pressure would be more relevant in this situation to identify any potential complications.
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