The practical nurse (PN) is caring for a client with fractured metatarsals after slamming a hand in the car door. After administering the prescribed hydrocodone/acetaminophen for pain, which intervention should the PN include in the client's care?
Implement ongoing assessments for signs of shallow or slow breathing.
Assess the skin daily for areas of ecchymosis or other signs of bleeding.
Encourage the client to resume normal activities after medication administration.
Observe the client for involuntary movements of the lips and tongue.
The Correct Answer is A
Choice A rationale:
After administering hydrocodone/acetaminophen for pain, the PN should closely monitor the client for signs of respiratory depression, which may manifest as shallow or slow breathing.
Ongoing assessments are crucial because respiratory depression is a potential adverse effect of opioid medications like hydrocodone. If this complication is detected early, appropriate interventions can be implemented to ensure the client's safety.
Choice B rationale:
Assessing the skin daily for areas of ecchymosis or other signs of bleeding is not directly related to the administration of hydrocodone/acetaminophen. While bruising and bleeding are possible side effects of some medications, this assessment is not the priority in this scenario.
Choice C rationale:
Encouraging the client to resume normal activities after medication administration is not appropriate in this situation. Hydrocodone/acetaminophen can cause drowsiness and impairment, so the client should be advised to avoid activities that require alertness or coordination until the effects of the medication are known.
Choice D rationale:
Observing the client for involuntary movements of the lips and tongue is relevant when administering antipsychotic medications, as these movements may be signs of tardive dyskinesia. However, it is not directly related to the use of hydrocodone/acetaminophen. The priority after administering this pain medication is to monitor for respiratory depression, as opioids can affect the respiratory system
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Offering a high protein diet may not be appropriate for a client with hepatic failure. High protein intake can lead to the accumulation of ammonia in the bloodstream, worsening hepatic encephalopathy. Therefore, this choice is not the best intervention for the client.
Choice B rationale:
Performing range of motion exercises is important for clients with hepatic failure to prevent complications related to immobility. However, it does not directly address the client's elevated pulse rate and changes in mental status.
Choice C rationale:
Weighing the client every morning is essential in monitoring fluid status and identifying signs of fluid retention or dehydration, which are common in hepatic failure. Changes in weight can help detect early signs of worsening hepatic function.
Choice D rationale:
Providing only distilled water may not be appropriate for a client with hepatic failure. While it is essential to monitor fluid intake, restricting all fluids to only distilled water could lead to electrolyte imbalances and further complications. Monitoring overall fluid intake and type is important for these clients.
Correct Answer is C
Explanation
The correct answer is Choice C. Following abdominal surgery, a client experiences wound evisceration.
Choice A rationale:
Cellulitis developing around a foot wound in a client with diabetes mellitus (DM) is a concerning situation, but it does not require the most immediate intervention compared to wound evisceration. Cellulitis is a bacterial skin infection that can usually be treated with antibiotics, while wound evisceration is a surgical emergency.
Choice B rationale:
Following suture removal from a stab wound, wound dehiscence is a serious complication, but it is not as immediately life-threatening as wound evisceration. Wound dehiscence is the separation of the wound edges after closure, and while it requires prompt attention, it does not involve the protrusion of organs from the wound.
Choice C rationale:
Wound evisceration, the protrusion of organs through a surgical incision, is a life-threatening complication that requires immediate intervention. The practical nurse should cover the exposed organs with a sterile, moist dressing and seek immediate medical assistance to prevent infection and further complications.
Choice D rationale:
For a client with a stage 4 sacral pressure ulcer developing purulent drainage is a concern, but it is not as immediately critical as wound evisceration. Proper wound care and infection management are essential, but the urgency level is lower compared to wound evisceration.
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