The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first?

The correct answer is choice C. Report the findings to the charge nurse. Choice A rationale:

Encouraging the client to drink fluids is not the priority in this situation. While hydration is important, the client's symptoms of muscle soreness, fatigue, and warm skin might indicate a potential adverse reaction to the statin medication, which requires immediate attention.

Choice B rationale:

Monitoring the client's serum lipid levels is not the priority at this moment. The client's current symptoms suggest a possible adverse reaction to the statin medication, and waiting for lipid level results may delay necessary interventions.

Choice C rationale:

Reporting the findings to the charge nurse is the priority action. The client's symptoms could be signs of rhabdomyolysis, a severe and potentially life-threatening condition where muscle breakdown releases toxic substances into the bloodstream. The charge nurse needs to be informed promptly so that appropriate interventions can be initiated.

Choice D rationale:

Administering a PRN dose of acetaminophen is not the priority in this situation. Acetaminophen may help with pain relief, but it will not address the potential underlying issue of muscle soreness and fatigue related to the statin medication.

The correct answer is choiceB. Remove the warm compress.

Choice A rationale:

Turning the lights on in the room would likely exacerbate the resident’s photophobia (sensitivity to light), causing more discomfort.Photophobia is a common symptom of bacterial conjunctivitis, and keeping the room dim can help alleviate this discomfort.

Choice B rationale:

Removing the warm compress is the correct action. Warm compresses can sometimes be used to relieve symptoms of conjunctivitis, but they are generally more appropriate for viral or allergic conjunctivitis.In the case of bacterial conjunctivitis, warm compresses can potentially worsen the infection by providing a warm, moist environment that promotes bacterial growth.Instead, a cool compress is often recommended to reduce inflammation and discomfort.

Choice C rationale:

Elevating the head of the bed can help reduce swelling and promote drainage, but it is not directly related to the immediate relief of eye pain and photophobia in bacterial conjunctivitis.This action might be more relevant for conditions involving fluid retention or respiratory issues.

Choice D rationale:

Offering an oral analgesic could help manage the resident’s pain, but it does not address the underlying issue of the warm compress potentially worsening the bacterial infection.Pain management is important, but it should be combined with appropriate measures to treat the infection and alleviate symptoms.