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

Explanation

Choice A rationale:

Obtaining a urine specimen for analysis is an important step in the assessment of the client with renal calculi. However, it is not the most immediate intervention when the client is experiencing severe flank pain and hematuria. Pain management should take precedence.

Choice B rationale:

This is the correct answer. Severe flank pain in a client with renal calculi is indicative of renal colic, which is typically excruciating. Administering a prescribed opioid analgesic is the priority to relieve the client's pain and distress.

Choice C rationale:

Straining the urine for the presence of stones is an essential nursing intervention to identify and collect any passed stones. However, it is not the most immediate action when the client is in severe pain. Pain management is the priority.

Choice D rationale:

Preparing the client for a prescribed computed tomography (CT) scan is an important diagnostic step to assess the location and size of the renal calculi. However, it is not the most immediate intervention when the client is in severe pain and distress. Pain management should come first.

A. Ask the wife to stop and assess the client's swallowing reflex. B. Give the wife a straw to help facilitate the client's drinking. C. Assist the wife and carefully give the client small sips of water. D. Obtain thickening powder before providing any more fluids.

Correct Answer is A

Explanation

Choice A rationale:

Ask the wife to stop and assess the client's swallowing reflex. Rationale: While assessing the client's swallowing reflex is important, the immediate priority is to provide hydration and comfort to the client, especially if the client is tearful and attempting to drink water. The nurse should assist the wife in providing small sips of water while being cautious and observing the client's ability to swallow safely.

Choice B rationale:

Give the wife a straw to help facilitate the client's drinking. Rationale: Giving the wife a straw may be helpful, but it does not address the client's immediate need for hydration and assistance with drinking. The nurse should actively assist in providing water to the client while assessing the client's ability to swallow safely.

Choice C rationale:

Assist the wife and carefully give the client small sips of water. Rationale: This is the correct answer. The nurse's immediate priority should be to assist the client with hydration. Providing small sips of water while being cautious and observing the client's ability to swallow safely is an appropriate action. This can help address the client's immediate needs for comfort and hydration.

Choice D rationale:

Obtain thickening powder before providing any more fluids. Rationale: While thickening powder may be necessary for clients with swallowing difficulties, it may cause unnecessary delay in providing hydration to the client in distress. The nurse should first provide water and assess the client's swallowing abilities. If thickened liquids are indicated, they can be administered later as per the healthcare provider's orders.

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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

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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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?