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","D","F","I"]
Explanation
Choice A rationale:
Starting an insulin drip at 0.1 u/kg/hr is a common treatment for diabetic ketoacidosis (DKA). The goal is to lower blood glucose levels while avoiding a rapid decrease that could lead to cerebral edema. Insulin infusions allow for precise control of the rate and can be adjusted as needed based on the patient’s response.
Choice B rationale:
Giving a long-acting insulin dose is not typically done during the acute treatment of DKA. The patient has already taken a dose of insulin glargine at home. Additional doses of long-acting insulin could potentially lead to hypoglycemia.
Choice C rationale:
Providing an oral medication that enhances insulin production would not be beneficial in this case. The patient has type 1 diabetes, which means her body does not produce insulin. Therefore, medications that stimulate insulin production would not be effective.
Choice D rationale:
Changing the intravenous fluid to 5% dextrose and 0.45% sodium chloride with 20 mEq potassium can help prevent hypoglycemia and hypokalemia, which are potential complications of DKA treatment. As blood glucose levels decrease with treatment, dextrose can help maintain appropriate glucose levels. Potassium is often depleted in DKA and needs to be replaced.
Choice E rationale:
Having the client drink as much as they can tolerate would not be appropriate at this time. The patient is currently experiencing nausea and vomiting, which could be exacerbated by oral fluid intake. Additionally, she is NPO (nothing by mouth), likely due to her unstable condition.
Choice F rationale:
Giving 1 L of 0.9% sodium chloride IV can help correct dehydration, which is common in DKA due to excessive urination caused by high blood glucose levels.
Choice G rationale:
Promoting removal of electrolytes with a diuretic would not be beneficial in this case. The patient is likely already dehydrated and may have electrolyte imbalances due to DKA. Using a diuretic could exacerbate these issues.
Choice H rationale:
Giving a multivitamin is not typically part of the acute treatment for DKA. While overall nutritional status is important in managing diabetes, it would not address the immediate concerns of hyperglycemia and acidosis in DKA.
Choice I rationale:
Replacing potassium as needed is crucial in the treatment of DKA. Potassium levels can drop rapidly during treatment as insulin allows potassium to move back into cells. Low potassium (hypokalemia) can cause dangerous heart rhythms and muscle weakness.
Correct Answer is C
Explanation
The correct answer is Choice C: Assign the remainder of medication administration to another Practical Nurse (PN) who is performing treatments.
Choice A reason: Denying the medication aide’s request to leave before all medications are given does not address the issue at hand and could potentially jeopardize patient care. It is important to acknowledge the medication aide’s request and find an appropriate solution that ensures patient safety and well-being.
Choice B reason: Delegating medication administration to unlicensed assistive personnel (UAP) who may not have the necessary training or authorization could lead to medication errors, adverse drug reactions, or other negative outcomes. It is essential to adhere to the scope of practice guidelines and facility policies when assigning tasks to UAPs.
Choice C reason: Reassigning the medication administration to another PN with the necessary qualifications and training ensures that patients receive their medications in a safe and timely manner. This action aligns with the practical nurse’s responsibility to supervise and delegate tasks appropriately, maintaining patient safety and upholding the standards of care.
Choice D reason: Documenting why medications were not given to each resident is an important aspect of maintaining accurate and comprehensive patient records. However, it does not address the immediate need to administer medications to residents, and it is not a substitute for ensuring that patients receive their prescribed treatments. Documentation should be completed after the appropriate steps have been taken to administer medications or arrange for an alternative solution.
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