The practical nurse (PN) is caring for a client who has a prescription for loratadine by mouth daily as needed. Which sign indicates to the PN that there is a need to administer the medication?

Ulceration on the corner of the upper lip.

Ecchymosis and petechiae on the legs

Red welts widespread over the chest.

Red papules and pustules on the face.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Red welts widespread over the chest.

Choice A rationale:

Ulceration on the corner of the upper lip does not indicate a need for loratadine administration. Loratadine is an antihistamine commonly used to relieve symptoms of allergies such as sneezing, runny nose, and itchy or watery eyes. Ulceration on the lip is not associated with an allergic reaction.

Choice B rationale:

Ecchymosis and petechiae on the legs are not related to the need for loratadine. These findings suggest potential bleeding or clotting disorders, and loratadine does not address such issues.

Choice C rationale:

Red welts widespread over the chest are indicative of hives (urticaria), which are often caused by allergic reactions. Loratadine can help alleviate the symptoms of hives by blocking histamine release, making it an appropriate choice for this condition.

Choice D rationale:

Red papules and pustules on the face are unlikely to be treated with loratadine. These skin manifestations may be related to various dermatological conditions, but not necessarily allergic reactions that loratadine is primarily used to manage.

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Correct Answer is B

Explanation

Choice A rationale:

The risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.

Choice B rationale:

Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.

Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.

Choice C rationale:

Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.

Choice D rationale:

Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.

A. Explains the examination and asks the client to sign the consent form. B. Obtains the medical record for the correct signed consent form prior to the examination. C. Asks if the client understands the exam and why the consent form must be signed. D. Witnesses the client's signature on the consent form after it is explained by the provider.

Correct Answer is D

Explanation

This is the best action that describes the responsibility of the PN because it ensures that the client has given informed consent for the invasive examination and that the consent form is valid and documented. The PN should verify that the provider has explained the examination, its risks and benefits, and alternative options to the client and that the client has agreed to proceed.

A. Explaining the examination and asking the client to sign the consent form is not the responsibility of the PN but of the provider who will perform the examination.

B. Obtaining the medical record for the correct signed consent form prior to the examination is not enough to ensure informed consent and may not involve any interaction with the client.

C. Asking if the client understands the exam and why the consent form must be signed is not enough to ensure informed consent and may not address any questions or concerns that the client may have.

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The practical nurse (PN) is caring for a client who has a prescription for loratadine by mouth daily as needed. Which sign indicates to the PN that there is a need to administer the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is caring for a client who has darkened membranes of the mouth and a smoky breath. Which priority nursing problem should the PN include in the plan of care?

Correct Answer is B

Explanation

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?

Correct Answer is D

Explanation

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