A client who is receiving a statin 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 takes priority?
Encourage the client to drink fluids.
Monitor the client's serum lipid levels.
Report the findings to the charge nurse.
Administer a PRN dose of acetaminophen.
The Correct Answer is C
The correct answer is choice C. Report the findings to the charge nurse. Choice A rationale:
Encouraging the client to drink fluids is not the priority in this situation. While hydration is important, the client's symptoms of muscle soreness, fatigue, and warm skin might indicate a potential adverse reaction to the statin medication, which requires immediate attention.
Choice B rationale:
Monitoring the client's serum lipid levels is not the priority at this moment. The client's current symptoms suggest a possible adverse reaction to the statin medication, and waiting for lipid level results may delay necessary interventions.
Choice C rationale:
Reporting the findings to the charge nurse is the priority action. The client's symptoms could be signs of rhabdomyolysis, a severe and potentially life-threatening condition where muscle breakdown releases toxic substances into the bloodstream. The charge nurse needs to be informed promptly so that appropriate interventions can be initiated.
Choice D rationale:
Administering a PRN dose of acetaminophen is not the priority in this situation. Acetaminophen may help with pain relief, but it will not address the potential underlying issue of muscle soreness and fatigue related to the statin medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is the action that the PN should emphasize for the client to take before self-administration of the nasal spray because it clears the nasal passages of mucus and debris and allows for better absorption of the medication. The PN should also instruct the client to shake the botle well, tilt the head slightly forward, insert the nozzle into one nostril, close the other nostril with a finger, and press the pump while inhaling gently.
Correct Answer is D
Explanation
The correct answer is choice D. Electrolytes.
Choice A rationale:
White blood cell count (WBC) is primarily used to detect infections, inflammation, and immune system disorders.While an abnormal WBC count can indicate various health issues, it is not directly related to numbness and tingling in the extremities.
Choice B rationale:
Hematocrit measures the proportion of red blood cells in the blood. It is useful for diagnosing anemia and other blood disorders.However, hematocrit levels are not typically associated with symptoms of numbness and tingling.
Choice C rationale:
Albumin and protein levels are important for assessing nutritional status and liver function.Low levels can indicate malnutrition or liver disease, but they are not directly linked to the sensation of numbness and tingling in the extremities.
Choice D rationale:
Electrolytes, such as sodium, potassium, calcium, and magnesium, play a crucial role in nerve function and muscle contraction. Imbalances in electrolyte levels can lead to symptoms like numbness, tingling, and muscle cramps.Therefore, reviewing the client’s electrolyte levels is essential when they report these symptoms.
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