The practical nurse (PN) receives prescriptions from the healthcare provider. Click to highlight the 3 prescriptions that the PN should perform right away.
A. Acetaminophen 600 mg PO every 6 hours PRN for pain or temperature greater than 100° F (37.7° C)
B. Contact precautions
C. Vancomycin 500 mg IV piggyback every 6 hours
D. Place peripheral IV
E. Change turban dressing by cleansing with sterile water, patting dry, applying dry gauze over incision, and wrapping head with kerlix
F. Strict intake and output
G. Clear liquid diet
Acetaminophen 600 mg PO every 6 hours PRN for pain or temperature greater than 100° F (37.7° C)
Contact precautions
Vancomycin 500 mg IV piggyback every 6 hours
Place peripheral IV
Change turban dressing by cleansing with sterile water, patting dry, applying dry gauze over incision, and wrapping head with kerlix
Strict intake and output
Clear liquid diet
The Correct Answer is ["B","C","E"]
A. Acetaminophen 600 mg PO every 6 hours PRN for pain or temperature greater than 100° F (37.7° C)
While acetaminophen is necessary for managing fever or pain, it is a PRN medication, meaning it is only given based on specific symptoms (temperature greater than 100°F or pain). Immediate administration is not required unless the client’s symptoms meet these criteria.
B. Contact precautions
Contact precautions are crucial for preventing the spread of MRSA, a highly contagious pathogen. Immediate implementation is necessary to protect both the client and others in the healthcare setting from infection.
C. Vancomycin 500 mg IV piggyback every 6 hours
Vancomycin is prescribed to treat the MRSA infection. It should be administered as ordered to manage the infection effectively and prevent complications from the surgical site infection.
D. Place peripheral IV
The peripheral IV has already been placed, as indicated by the notes. This action would have been necessary before starting the IV medication orders but is not an immediate task at this time.
E. Change turban dressing by cleansing with sterile water, patting dry, applying dry gauze over incision, and wrapping head with kerlix
Changing the turban dressing is necessary to manage the infection at the surgical site. This must be done according to the prescribed procedure to maintain sterile conditions and support healing.
F. Strict intake and output
While monitoring intake and output is important, it does not need to be done immediately but should be started as per the order to monitor the client’s fluid balance over time.
G. Clear liquid diet
Initiating a clear liquid diet is important for nutritional support, but it does not need to be started immediately. It is part of the general care plan but does not have the same urgency as infection control and medication administration
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"}}
Explanation
- Leaving an Older Adult in a Public Space
- Abandonment: Leaving the client alone in a public space can be considered abandonment, as it involves a failure to provide necessary care and supervision.
- Untreated Pressure Injuries
- Neglect: Untreated pressure injuries indicate a failure to provide adequate care and preventative measures, which is a form of neglect.
- Oversedation
- Physical Abuse: Administering excessive medication or sedation without proper medical justification can be a form of physical abuse.
- Poor Personal Hygiene
- Neglect: Poor personal hygiene often results from neglect, where the caregiver fails to assist with or encourage personal care practices.
- Depression or Withdrawn Behavior
- Neglect: Depression or withdrawn behavior can result from neglectful conditions, such as a lack of social interaction or emotional support.
- Bruises in Various Stages of Healing
- Physical Abuse: Bruises in various stages of healing are a classic sign of physical abuse, indicating that the client has been subjected to physical harm.
Correct Answer is B
Explanation
A. Re-lubricating the tubing and re-inserting it is unnecessary if the enema solution is not infusing; the primary issue is likely related to the tubing's position or the height of the container.
B. Inserting the tubing an additional three inches into the rectum ensures that it is positioned correctly for the solution to flow. If the tubing is not inserted far enough, the solution may not enter the rectum.
C. Raising the saline container higher is not needed since it is already six inches above the client’s body. The problem is more likely related to the tubing’s depth rather than the height of the container.
D. Instructing the client to take deep breaths does not affect the infusion of the enema solution. The solution's flow is influenced by the mechanics of the enema administration, not by the client’s breathing.
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