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.

Answer and Explanation

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

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Correct Answer is B

Explanation

The correct answer isChoice B.

Choice B rationale:

The practical nurse (PN) should instruct the unlicensed assistive personnel (UAP) to keep the client's skin clean and dry. Proper skin care is essential for a client with urinary and fecal incontinence to prevent the development of pressure ulcers. Keeping the skin clean and dry helps reduce moisture-related skin breakdown.

Choice A rationale:

Encouraging the client to rest quietly in bed is not directly related to preventing pressure ulcers. While adequate rest is essential for overall health, it does not specifically address the risk of pressure ulcers in an incontinent client.

Choice C rationale:

Obtaining supplies for contact precautions is unrelated to the client's risk of developing a sacral pressure ulcer. Contact precautions are used to prevent the spread of infectious diseases and do not address skin integrity.

Choice D rationale:

Documenting any changes in skin integrity is important, but it is the responsibility of the healthcare team, including the PN. However, this response does not provide proactive measures to prevent the pressure ulcer from occurring in the first place, which is the primary concern in this situation.

A. Irregular heart rate. B. Profuse diaphoresis. C. Lower leg weakness. D. Full facial ﬂushing.

Correct Answer is A

Explanation

This is the finding that the PN should report to the charge nurse because it indicates a possible complication of Guillain-Barre syndrome, which is autonomic dysfunction. This can aﬀect the cardiac, respiratory, and gastrointestinal systems and cause life-threatening problems such as arrhythmias, hypotension, or respiratory failure. The PN should monitor the client's vital signs closely and report any abnormal changes.

B. Profuse diaphoresis is not a priority finding and may be related to other factors such as fever, anxiety, or medication side eﬀects.

C. Lower leg weakness is an expected finding in Guillain-Barre syndrome and does not need to be reported unless it progresses rapidly or aﬀects the respiratory muscles.

D. Full facial ﬂushing is not a priority finding and may be related to other factors such as vasodilation, inﬂammation, or medication side eﬀects.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with urinary and fecal incontinence has an increased risk for developing a sacral pressure ulcer. Which information should the practical nurse (PN) give the unlicensed assistive personnel (UAP) who is assisting with the care of the client?

Correct Answer is B

Explanation

While caring for a client with Guillain-Barre syndrome, which finding should the practical nurse (PN) report to the charge nurse?

Correct Answer is A

Explanation

The practical nurse (PN) is reinforcing dietary instructions with a client who has renal disease regarding the need to limit salt intake. Which selections for a lunch meal indicate to the PN that the client is following the diet plan? (Select all that apply.).

An unlicensed assistive personnel (UAP) is completing an orientation assignment and is caring for a client who needs assistance with bathing. What is the best way for the practical nurse (PN) to evaluate this UAP's performance?

An older male client is returning to the surgical unit after a total right knee replacement. Which assessment findings are most important for the practical nurse (PN) to document in this client's electronic medical record (EMR)?

The practical nurse (PN) finds a postoperative client lying in bed with an unsecured surgical dressing as seen in the picture. After reinforcing the dressing, which follow-up assessment is most important for the PN to implement?

When monitoring a client's abdominal incision, the practical nurse (PN) observes a large amount of sanguineous drainage on the dressing. Which client data collection should the PN complete first?

The practical nurse (PN) is reviewing a client's recent ophthalmic screening test results. Findings of optic neuropathy, loss of peripheral vision, and increased intraocular pressure are consistent with which medical condition?

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?