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 B

Explanation

To prevent injury in a female client with immune thrombocytopenic purpura (ITP) who is transferred to a long-term care facility for physical rehabilitation, the most important action for the practical nurse to implement is to ensure the client has minimal clutter in the room.

ITP is a condition characterized by a low platelet count, which can result in an increased risk of bleeding and bruising. Clutter in the room can pose a hazard and increase the risk of injury. The client may accidentally bump into objects or trip over items, potentially leading to falls or injuries.

Incorrect:

A- Assessing the client for nerve pain or paralysis is important but may not be directly related to preventing injury in this context. It is essential to address these concerns but not the most important action in preventing injury.

C- Evaluating the client's neurological status after exercising is important for overall assessment and monitoring but does not specifically address the prevention of injury.

D- Monitoring the client's blood cell laboratory values is essential for managing the client's condition but does not directly address preventing injury. It focuses more on the medical management of the client's ITP.

A. Document the client's loss of memory in the record. B. Remind the client what day of the week it is. C. Encourage the client to rest during the day. D. Notify the family of the change in the client's condition.

Correct Answer is B

Explanation

Choice A: Document the client's loss of memory in the record.

While it's important to document changes in a patient's condition, this should not be the first action. The confusion might be temporary and due to the new environment. It's crucial to first address the patient's immediate needs.

Choice B: Remind the client what day of the week it is.

This is the best action to take. The patient is likely experiencing "relocation stress syndrome," which can cause confusion and disorientation in a new environment. Reminding her of the day can help reorient her and alleviate her confusion.

Choice C: Encourage the client to rest during the day.

While rest is important, it doesn't directly address the patient's confusion about the day of the week. Furthermore, excessive daytime sleep can disrupt the patient's sleep-wake cycle and potentially exacerbate confusion.

Choice D: Notify the family of the change in the client's condition.

While it's important to keep the family informed, this should not be the first action. The nurse should first address the patient's confusion and monitor her to see if the confusion persists or improves.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client with immune thrombocytopenic purpura (ITP) is transferred to a long term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement?

Correct Answer is B

Explanation

An older female adult who was admitted to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

Correct Answer is B

Explanation

On the first day after a cesarean section, a client who is a primipara is being assisted to the bathroom for the first time. The client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. Which action should the practical nurse (PN) take?

The practical nurse (PN) is assisting with the admission of a client with complications of left-sided heart failure. Which focused assessment should the PN implement first?

The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) to clean the hearing aid of an older adult resident of a long-term care facility. Which instructions should the PN provide to the UAP? (Select all that apply.)

A male client attends a community support program for mentally impaired and chemical-abusing clients. The client tells the practical nurse (PN) that his drugs of choice are cocaine and heroin. What is the greatest health risk for this client?

The healthcare provider prescribed octreotide 150 mcg/day subcutaneously for a client with dumping syndrome. The medication is available in 0.2 mg/mL vials. How many mL should the practical nurse (PN) administer? (Enter numerical value only. If rounding is required, round to the nearest hundredth)

After completing post-anesthesia recovery assessments, the registered nurse (RN) asks the practical nurse (PN) to transfer four clients, each two hours post-birth, to the postpartum unit. Which client should the PN ask the RN to reassess prior to transfer?

A client is using an incentive spirometer on the first postoperative day after an inguinal herniorrhaphy. The practical nurse (PN) should reteach the proper use of the spirometer when the client demonstrates which action.