The practical nurse (PN) is assisting with the plan of care for a client who is experiencing torticollis from a traumatic injury sustained during a football game. The client received a prescription for tramadol. Which intervention should the PN include in the client's plan of care?

Encourage the client to resume normal activities after medication administration.

Observe the client for involuntary movements of the lips and tongue every day.

Perform a daily whisper test of the client's hearing to detect symptoms of ototoxicity.

Implement ongoing assessments for signs of shallow or slow breathing.

Answer and Explanation

The Correct Answer is D

Tramadol is an opioid analgesic that can depress the respiratory system and potentially cause respiratory depression. Therefore, it is crucial for the PN to closely monitor the client's breathing pattern, depth, and rate. Assessing for signs of shallow or slow breathing is important to detect any potential respiratory depression and take appropriate action promptly.
The other options listed are not directly related to the administration of tramadol:

A. Encouraging the client to resume normal activities after medication administration is not an appropriate intervention for a client experiencing torticollis. The focus should be on pain management, rest, and implementing measures to relieve the torticollis.
B. Observing the client for involuntary movements of the lips and tongue every day is not specifically related to tramadol. This intervention is more relevant to monitoring for tardive dyskinesia, a side effect associated with certain antipsychotic medications.
C. Performing a daily whisper test of the client's hearing to detect symptoms of ototoxicity is not necessary with tramadol. Ototoxicity refers to damage to the inner ear, often caused by specific medications, but tramadol is not known to cause ototoxic effects.

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Correct Answer is A

Explanation

The practical nurse (PN) should observe minimal time, maximum distance, and protective shielding when administering direct care to a client who has four gold seed implants on a chest wall tumor.
Minimal time refers to limiting the duration of direct exposure to the client with the gold seed implants. This helps minimize the nurse's exposure to radiation.
Maximum distance refers to maintaining a safe distance from the client with the gold seed implants. The nurse should try to stay as far away as possible while still being able to provide necessary care.
Protective shielding involves using lead aprons, gloves, and other appropriate shielding materials to protect oneself from radiation exposure. These protective measures help reduce the nurse's exposure to radiation during care activities.
B. Rotating assignments with other staff during the shift may not be necessary in this situation unless there are specific staffing requirements or guidelines in place. The primary focus should be on minimizing the nurse's exposure to radiation through time, distance, and shielding.
C. Virtual observation and wearing a film badge for exposure are not applicable in this context. These measures are more relevant for monitoring radiation exposure over time and do not directly address the precautions needed during direct care.
D. Standard precautions with negative pressure isolation are not specifically indicated for a client with gold seed implants. Negative pressure isolation is typically used for clients with infectious diseases that require airborne precautions, and it is not directly related to radiation precautions.

A. Ask the client if she has previously been catheterized. B. Consult with the charge nurse about the catheter. C. Obtain a 30 mL syringe and a vial of sterile water. D. Position the client and observe the urinary meatus.

Correct Answer is B

Explanation

A. Asking the client if she has previously been catheterized is important for understanding her history and comfort level but is not the first action to take in preparation for the procedure.
B. Consulting with the charge nurse about the catheter may be appropriate if there are concerns about the catheter type, but it is not a priority before starting the procedure.
C. Obtaining a 30 mL syringe and a vial of sterile water is essential for inflating the balloon after catheter insertion, but this can be done after positioning the client.
D. Positioning the client and observing the urinary meatus is the first action the PN should take. This step ensures the client is comfortable and provides a clear view for proper catheter insertion, which is crucial for the procedure's success.

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The practical nurse (PN) is assisting with the plan of care for a client who is experiencing torticollis from a traumatic injury sustained during a football game. The client received a prescription for tramadol. Which intervention should the PN include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has four gold seed implants on a chest wall tumor is on radiation precautions. What basic precautions should the practical nurse (PN) observe when administering direct care to this client?

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

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