The practical nurse (PN) is making a home visit to an older male adult who was recently diagnosed with Herpes zoster (shingles). The client reports the onset of severe burning pain along the right side of his trunk. What action should the PN take?
Administer a prescribed PRN dose of analgesic.
Obtain an oxygen tank for home administration.
Give the next prescribed dose of antiviral medication.
Notify the nursing supervisor of the uncontrolled pain.
The Correct Answer is A
This is the best action for the PN to take because it provides immediate relief for the client's pain, which can be severe and debilitating in Herpes zoster. The PN should also assess the client's pain level, location, and characteristics and document the response to the medication.
B. Obtaining an oxygen tank for home administration is not indicated for this client and does not address his pain issue. Herpes zoster does not affect the respiratory system and does not cause hypoxia or dyspnea.
C. Giving the next prescribed dose of antiviral medication is not a priority for this client and may not have an immediate effect on his pain. Antiviral medication can help reduce the duration and severity of Herpes zoster, but it does not provide analgesia.
D. Notifying the nursing supervisor of uncontrolled pain is not a priority for this client and may delay his pain relief. The PN should notify the nursing supervisor only if the prescribed analgesic is ineffective or causes adverse effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
The correct answer is choice C. Initiation of changes in infection control measures.
Choice A rationale:
Limiting the client’s fluid intake to avoid hemodilution is not relevant to managing a decreased ANC. Hemodilution is not a concern in this context, and fluid intake should generally be maintained to support overall health.
Choice B rationale:
Avoiding exposure to cold temperatures is not directly related to managing a decreased ANC. While keeping the client comfortable is important, it does not address the increased risk of infection associated with neutropenia.
Choice C rationale:
Initiation of changes in infection control measures is crucial when a client’s ANC decreases. Neutropenia increases the risk of infections, so enhanced infection control practices, such as strict hand hygiene, use of protective isolation, and monitoring for signs of infection, are essential to protect the client.
Choice D rationale:
Increasing the client’s dietary servings of fruits and vegetables is generally beneficial for overall health but does not specifically address the immediate risks associated with a decreased ANC. In fact, certain fresh fruits and vegetables might need to be avoided if they pose a risk of introducing pathogens.
Correct Answer is D
Explanation
This is the finding that the PN should instruct the postpartum client to report to the charge nurse because it may indicate an infection, such as endometritis, mastitis, or urinary tract infection, that requires prompt treatment. The PN should also instruct the client to monitor for other signs of infection, such as foul-smelling lochia, redness or tenderness of the breasts, or dysuria.
A. Increased diaphoresis during the day and night is a normal finding in the postpartum period and does not need to be reported. It is caused by hormonal changes and fluid shifts that occur after delivery.
B. Breast engorgement on the fourth postpartum day is a normal finding in the postpartum period and does not need to be reported. It is caused by increased blood flow and milk production in the breasts.
C. Lochia color that changes to light pink or white is a normal finding in the postpartum period and does not need to be reported. It indicates that the uterine lining is healing and regenerating after delivery.
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