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 D

Explanation

Gently blowing the nose helps to clear any mucus or debris from the nasal passages, allowing for better delivery and absorption of the medication. It also helps to ensure that the nasal passages are clear and open, allowing the medication to reach its intended target.
A. Deep breathing and coughing are unrelated to the administration of nasal spray and are not necessary before using the medication.
B. Checking glucose levels before and after administration is not relevant for fluticasone furoate nasal spray. Glucocorticoid nasal sprays are not typically associated with significant effects on blood glucose levels.
C. Exhaling through the mouth is not a specific action required before using the nasal spray. It may be a general instruction for some other respiratory therapies or procedures, but it is not directly related to the administration of the nasal spray.

A. A client with continuous urinary bladder irrigation via a 3-way catheter. B. A client with urinary urgency and incontinence who is asking for a bedpan. C. A client with a full urinary bedside drainage unit after receiving a diuretic. D. A client with paraplegia who needs an urinary condom-catheter change.

Correct Answer is A

Explanation

A client with continuous urinary bladder irrigation via a 3-way catheter: This task requires specialized knowledge and skill to ensure proper management of the irrigation process, monitoring for complications, and adjusting the irrigation rate as needed. It falls within the scope of practice of the PN, who has the necessary training and expertise.
B. A client with urinary urgency and incontinence who is asking for a bedpan: This task can be safely and appropriately assigned to the UAP. Assisting the client with using a bedpan for voiding is a basic care task that does not require specialized nursing knowledge or skills.
C. A client with a full urinary bedside drainage unit after receiving a diuretic: Emptying a full urinary bedside drainage unit is a task that can be assigned to the UAP. It involves routine emptying and documentation of the drainage bag and does not require specialized nursing knowledge or skills.
D. A client with paraplegia who needs a urinary condom-catheter change: This task requires specialized knowledge and skill to perform a sterile procedure, ensure proper placement and securement of the condom catheter, and assess for any complications. It falls within the scope of practice of the PN, who has the necessary training and expertise.

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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 D

Explanation

The practical nurse (PN) is assigning tasks to an unlicensed assistive personnel (UAP) who is giving basic care to a group of residents in a long-term care facility. Which client's task should be completed by a PN, rather than the UAP?

Correct Answer is A

Explanation

An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. What action should the PN take?

A male preoperative client who has already signed the informed consent for a surgical procedure confides to the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take?

The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using the thermometer. Which action should the PN take first?

An adult female client with type 1 diabetes mellitus is receiving NPH insulin 35 units each morning. Which finding should the practical nurse (PN) document as evidence that the amount of insulin is inadequate?

The practical nurse (PN) observes unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in a high position. Which action should the PN take?

The practical nurse (PN) receives shift reports for four newborns in the full-term newborn nursery. Which infant should the PN assess first?