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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the action that the PN should implement when assessing a client with an indwelling urinary catheter and observing that the catheter drainage bag, which is half-full, is attached to the side rail and the tubing is looped on the bed. Attaching the drainage bag to the bed frame ensures that the bag is below the level of the bladder and prevents backflow of urine, which can cause infection or obstruction. The PN should also straighten the tubing and avoid any kinks or loops that may interfere with the drainage.
Correct Answer is ["B","C","E"]
Explanation
The practical nurse (PN) should provide the following instructions to the unlicensed assistive personnel (UAP) for cleaning the hearing aid of an older adult resident:
A- Keep the battery door closed during storage: his is incorrect because the battery door should be kept open when the hearing aid is not in use. Keeping it open helps prevent moisture buildup inside the device.
B- Remove ear wax from the device's surface: Earwax accumulation can affect the performance of the hearing aid. Instructing the UAP to clean the device's surface and remove any visible ear wax will help maintain optimal functioning.
C- Verify that the device is labeled with the client's identification: Labeling the device with the client's identification is crucial to ensure that it is returned to the correct person. This step helps prevent mix-ups or misplacements of hearing aids among residents.
D- This is not appropriate as it can expose the device to heat and sunlight, which could damage it.
E- Observe and report any ear drainage after removing the device: After removing the hearing aid, the UAP should observe the client's ears for any signs of drainage or abnormal discharge. If ear drainage is noticed, it should be reported to the PN or appropriate healthcare provider for further assessment and management.
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