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.

a) Administer a PRN dose of acetaminophen.

This is not the priority action by the PN because it does not address the underlying cause of the client's symptoms. Acetaminophen is an analgesic and antipyretic medication that can help reduce pain and fever. However, it does not treat inﬂammation, infection, or allergy, which may be the reasons for the client's muscle soreness, fatigue, and warm skin. The PN should administer a PRN dose of acetaminophen only after reporting the findings to the charge nurse and obtaining an order from the health care provider.

b) Encourage the client to drink ﬂuids.

This is not the priority action by the PN because it does not address the underlying cause of the client's symptoms. Drinking ﬂuids can help maintain hydration and electrolyte balance in the body, which are important for normal functioning of cells and organs. However, it does not treat inﬂammation, infection, or allergy, which may be the reasons for the client's muscle soreness, fatigue, and warm skin. The PN should encourage the client to drink ﬂuids only after reporting the findings to the charge nurse and obtaining an order from the health care provider.

d) Monitor the client's serum lipid levels.

This is not the priority action by the PN because it is not related to the client's symptoms. Serum lipid levels are measures of fats and cholesterol in the blood, which are important for energy production, hormone synthesis, and cell membrane structure. However, they are not related to inﬂammation, infection, or allergy, which may be the reasons for the client's muscle soreness, fatigue, and warm skin. The PN should monitor the client's serum lipid levels only if they are prescribed a medication that can aﬀect lipid metabolism, such as statins or fibrates.

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

Explanation

The correct answers are Choices B, C, D, and E.

Choice A rationale: Dentures should remain in place to preserve facial structure and dignity. Removing them may cause facial collapse, distressing the family during viewing and violating postmortem presentation standards.

Choice B rationale: Gently closing the eyes prevents ocular drying and maintains a peaceful appearance. If eyelids resist closure, moistened cotton balls may be used temporarily to assist with natural positioning.

Choice C rationale: Placing a small pillow under the head elevates it, preventing blood pooling and facial discoloration due to livor mortis. It supports a natural, respectful presentation for family viewing.

Choice D rationale: Applying a body shroud ensures hygienic containment and visual dignity. It’s standard practice before transport and aligns with institutional protocols for respectful postmortem care.

Choice E rationale: Removing resuscitation equipment reduces trauma triggers for the family, restores environmental calm, and supports emotional closure. It also complies with facility standards for postmortem room preparation.

A. A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech. B. A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech. C. A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech. D. After having a few drinks at a local seafood restaurant, the client’s husband noticed his wife’s speech became difficult to understand. E. 1915: Client arrives via personal car to emergency department with facial drooping and garbled speech.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A rationale:

The client’s presentation of a noticeable facial droop and garbled speech are classic symptoms of a stroke. These symptoms indicate that the brain is not receiving enough oxygen, which can lead to permanent damage if not treated immediately. Therefore, this client requires immediate health interventions.

Choice B rationale:

This choice is identical to Choice A. The client’s noticeable facial droop and garbled speech are indicative of a stroke and require immediate attention.

Choice C rationale:

This choice is also identical to Choices A and B. The client’s symptoms are indicative of a stroke, which is a medical emergency that requires immediate intervention.

Choice D rationale:

While the change in the client’s speech after having a few drinks at a restaurant could be due to alcohol consumption, it could also be a symptom of a stroke, especially when combined with the facial droop. However, this choice does not directly indicate the need for immediate health interventions as it lacks the specificity of the symptoms compared to Choices A, B, and C.

Choice E rationale:

The time of arrival and mode of transportation do not directly indicate the need for immediate health interventions. However, the mention of facial drooping and garbled speech upon arrival at the emergency department reinforces the urgency of the situation, as these are classic symptoms of a stroke. In conclusion, Choices A, B, C, and E all highlight data that indicate the client is in need of immediate health interventions due to potential stroke symptoms. It’s important to note that strokes require immediate medical attention to minimize brain damage and potential complications. Normal ranges for lab parameters would not apply in this scenario as it’s based on clinical observations rather than laboratory findings.

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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?

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

Explanation

Correct Answer is ["A","B","C","E"]

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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?