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 A
Explanation
The correct answer is choice A: Tell her to empty her bladder and call if she has a bloody show.
Choice A rationale:
The client is 39 weeks gestation and experiencing mild, irregular contractions. The fact that her cervix is already 3 cm dilated and the presenting part is at -1 station indicates that she is in early labor. Emptying the bladder can help relieve pressure on the cervix and promote progress in labor. Instructing her to call if she has a bloody show is essential because it could indicate that her labor is advancing, and she may need to come to the labor and delivery unit soon.
Choice B rationale:
Directing her to come to the unit for impending delivery is not appropriate at this stage, as she is only experiencing mild, irregular contractions and is likely in early labor. Coming to the unit too early may lead to unnecessary interventions and discomfort for the client.
Choice C rationale:
Asking the charge nurse for further instructions is not necessary in this situation. The client's condition is not emergent, and the practical nurse can handle the situation appropriately based on the information provided.
Choice D rationale:
Encouraging ambulation until the contractions are regular might be beneficial in some cases to promote labor progress. However, given that the client is already 3 cm dilated and experiencing mild, irregular contractions, it's better to address the issue of bladder emptying and potential bloody show.
Correct Answer is A
Explanation
A thready pulse is a weak and rapid pulse that is easily obliterated by light pressure. It indicates poor blood flow and perfusion, and may be caused by conditions such as shock, dehydration, or hemorrhage.
The other options are not correct because:
- A missing pulse is a pulse that is absent or cannot be detected, even with firm pressure. It indicates a complete blockage of blood flow, and may be caused by conditions such as arterial occlusion, embolism, or trauma.
- Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.
- Pulse skips beats is a documentation of an irregular pulse rhythm, not a pulse volume. It indicates that the heart beats are unevenly spaced, and may be caused by conditions such as arrhythmia, stress, or caffeine intake.
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