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 C
Explanation
Croup is a viral infection that affects the upper airways, causing inflammation and narrowing of the air passages. In severe cases, it can lead to respiratory distress, including increased work of breathing and decreased oxygen saturation levels. Monitoring the child's oxygen saturation level using a pulse oximeter is an essential intervention to assess the severity of respiratory distress and the need for further interventions.
A. Encouraging the child to drink cool, clear liquids can help soothe the throat and prevent dehydration.
B. Instructing the mother to play with the child for stimulation and distraction can help provide comfort and alleviate anxiety.
D. Administering acetaminophen as needed (PRN) can help reduce fever and discomfort. However, none of these interventions directly address the potential respiratory distress and the need for oxygenation assessment.
Correct Answer is B, A, C, D
Explanation
The correct sequence for the interventions when caring for a client with a tracheostomy tube, after donning sterile gloves, is as follows:
Hyperoxygenate with a bag valve mask (BVM) using a nondominant hand. Insert sterile suction catheter in tracheostomy tube.
Activate suction by covering the catheter opening. Withdraw and rotate the catheter while suction is applied.
The first step is to hyperoxygenate the client using a bag valve mask (BVM) with the nondominant hand. This helps to ensure that the client receives adequate oxygenation during the suctioning procedure.
Next, the sterile suction catheter is inserted into the tracheostomy tube. The catheter is carefully advanced until resistance is met, ensuring it does not force its way in.
After the catheter is inserted, the suction is activated by covering the catheter opening. This creates negative pressure and allows for the removal of secretions.
Finally, the catheter is withdrawn and rotated while suction is applied. This helps to thoroughly suction the secretions from the tracheostomy tube.
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