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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Step 1 is to convert the child’s weight from pounds to kilograms since the dosage is prescribed in mg/kg. We know that 1 kg is approximately 2.2 lbs. So, the child’s weight in kg is 55 lbs ÷ 2.2 = 25 kg (rounded to the nearest whole number for simplicity).
Step 2 is to calculate the total daily dosage. The prescription is for 150 mg/kg/day. So, the total daily dosage is 150 mg/kg/day × 25 kg = 3750 mg/day.
So, the correct answer is, after analysing all choices, the nurse should administer 3750 mg of cefotaxime each day.
Correct Answer is D
Explanation
Choice A rationale:
Tetracycline antibiotics can form insoluble complexes with calcium, reducing their absorption when taken together. Therefore, advising the client to continue taking calcium supplements with food while on tetracycline therapy is not recommended as it may decrease the effectiveness of the antibiotic.
Choice B rationale:
The nurse should advise the client to avoid taking calcium supplements while on tetracycline therapy. Calcium-containing products (such as supplements, dairy products, and antacids) should be taken at least 2 hours before or after tetracycline administration to minimize the interference with drug absorption.
Choice C rationale:
Taking calcium supplements with tetracycline, even with plenty of water, can still lead to reduced drug absorption due to the formation of insoluble complexes. Therefore, this advice is not appropriate.
Choice D rationale:
The nurse should recommend that the client take calcium supplements at least 2 hours before or after tetracycline. This approach ensures that the client receives the full therapeutic benefit of the antibiotic while still meeting their calcium needs separately.
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