In preparing to discontinue a client's saline lock, the practical nurse (PN) notes that the client is receiving an antiplatelet medication. Which action should the PN implement?

Leave the saline lock in place and notify the charge nurse.

Plan to apply pressure over the site for several minutes.

Encourage the client to drink additional oral fluids.

Prepare a warm pack to apply after removing the lock

Answer and Explanation

The Correct Answer is B

Antiplatelet medications, such as aspirin or clopidogrel, are prescribed to prevent the formation of blood clots by inhibiting platelet aggregation. These medications can increase the risk of bleeding or prolonged bleeding time. Therefore, when removing the saline lock, applying pressure over the site for several minutes helps to minimize the risk of bleeding and promote hemostasis.
A. Leaving the saline lock in place and notifying the charge nurse may not be necessary unless there are specific concerns or complications related to the client's condition.
C. Encouraging the client to drink additional oral fluids is not directly related to the discontinuation of the saline lock and the potential risk of bleeding associated with antiplatelet medication.
D. Preparing a warm pack to apply after removing the lock is not necessary for this situation. Warm packs are typically used for comfort or to promote circulation, but they are not directly related to the risk of bleeding associated with antiplatelet medication.

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Correct Answer is A

Explanation

The client's statements suggest significant distress, feelings of being a burden, and a sense of hopelessness related to their obsessive-compulsive disorder (OCD). Given the severity of these statements, it is crucial for the PN to assess the client's risk of suicide or self-harm. Asking directly about suicidal thoughts or considering suicide as an option allows the PN to evaluate the immediate safety of the client and take appropriate actions to ensure their well-being.
While the other options may also provide relevant information, they are not as critical as assessing the client's risk of suicide.
B. Questioning about which rituals are most often used to reduce anxiety can help gather information about the client's specific OCD symptoms and coping mechanisms.
C. Determining what makes the client think people are laughing can provide insight into their perception of how others view them, but it may not address the immediate risk of harm.
D. Asking about the impact of obsessions and compulsions on sleep can help assess the client's overall functioning, but it does not address the immediate risk of suicide.

A. Administer a PRN dose of acetaminophen. B. Encourage the client to drink ﬂuids. C. Report the findings to the charge nurse. D. Monitor the client's serum lipid levels.

Correct Answer is C

Explanation

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.

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In preparing to discontinue a client's saline lock, the practical nurse (PN) notes that the client is receiving an antiplatelet medication. Which action should the PN implement?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

The practical nurse (PN) believes that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Which action should the PN take?

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A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. Which response should the practical nurse (PN) make?

The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?