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 ["A","B","C","H"]
Explanation
Choice A rationale:
A Speech Therapist is crucial in this case. The patient presented with garbled speech, which indicates a possible speech impairment. A speech therapist can evaluate the patient’s speech and language skills and provide therapy to improve any deficits, which can significantly enhance the patient’s quality of life.
Choice B rationale:
A Case Manager is essential in coordinating the patient’s care. They ensure that the patient’s healthcare needs are met and that the patient is receiving appropriate treatments. They also coordinate with various healthcare professionals and may assist with insurance issues or discharge planning.
Choice C rationale:
A Physical Therapist can help the patient regain physical strength and mobility that might have been affected by the stroke. They can provide exercises and treatments to improve balance, coordination, and muscle strength, which can help the patient regain independence in their daily activities.
Choice D rationale:
A Pharmacy Technician is not typically involved in direct patient care or recovery. Their role is more focused on assisting pharmacists with dispensing medication and other administrative tasks in a pharmacy setting.
Choice E rationale:
The Chief Nursing Officer (CNO) is a high-level executive role that oversees nursing staff across an entire healthcare organization. While they play a crucial role in ensuring quality nursing care, they would not be directly involved in individual patient recovery.
Choice F rationale:
A Respiratory Therapist could be helpful if the patient had respiratory issues or complications related to the stroke, but given the information provided, it does not appear that respiratory therapy is needed in this case.
Choice G rationale:
A Medical Assistant typically performs administrative and clinical tasks in healthcare settings but does not specialize in rehabilitation or recovery care for stroke patients.
Choice H rationale:
An Occupational Therapist is vital for stroke recovery. They can help the patient regain skills needed for daily living activities that might have been affected by the stroke, such as eating, dressing, and bathing. They can also provide strategies to compensate for any lasting deficits from the stroke. In summary, for a comprehensive recovery plan for this patient who has had a stroke, an interdisciplinary team involving a Speech Therapist (A), Case Manager (B), Physical Therapist ©, and Occupational Therapist (H) would be most beneficial.
Correct Answer is B
Explanation
Choice A rationale:
Granulating tissue in a foot ulcer is a positive sign of wound healing, but it may not be directly related to the effectiveness of pregabalin in treating diabetic peripheral neuropathy. The primary goal of pregabalin in this context is to reduce pain and neuropathic symptoms.
Choice B rationale:
A reduced level of pain is the most relevant indicator of the effectiveness of pregabalin in treating diabetic peripheral neuropathy. Pregabalin is an antiepileptic medication used to manage neuropathic pain. A decrease in pain indicates that the medication is effectively managing the client's symptoms.
Choice C rationale:
Improved visual acuity is not directly related to the effectiveness of pregabalin in treating diabetic peripheral neuropathy. Pregabalin primarily targets neuropathic pain and sensory symptoms, not visual function.
Choice D rationale:
A full volume of pedal pulses is a positive sign of adequate circulation in the lower extremities, but it may not be directly related to the effectiveness of pregabalin in treating neuropathy symptoms. The primary goal of pregabalin in this context is pain management.
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