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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C"]

Explanation

A. A broken arm from a volleyball game is an injury that is not necessarily indicative of family violence; it appears to be an accident.
B. Multiple old fractures in a young child may indicate possible abuse or family violence, as this pattern is concerning for potential neglect or physical harm.
C. Multiple bruises on the hands and face of a married man may suggest a pattern of domestic violence, which should be reported for further assessment.
D. Soiled clothing and foul body odor may indicate poor living conditions but are not specific indicators of family violence.
E. A skull fracture from an automobile collision is likely an accident, not necessarily indicative of family violence unless further evidence suggests abuse.

A. Respiratory rate 18 breaths/minute B. Heart rate 101 beats/minute C. Capillary refill 2 seconds D. Breath sounds clear and equal bilaterally E. Turban dressing is saturated with serosanguinous drainage F. Blood pressure 140/84 mm Hg G. Temperature 101.9° F (38.8° C) H. Client is awake and alert

Correct Answer is ["B","E","G"]

Explanation

A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assisting with data collection for clients who have been admitted to the emergency department. What clients should the PN report to the nurse for further intervention for possible family violence? Select all that apply.

Correct Answer is ["B","C"]

Explanation

Exhibits The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.

Correct Answer is ["B","E","G"]

Explanation

The practical nurse (PN) administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory values should the PN monitor? Select all that apply.

A client who is multiparous at 38-weeks gestation is admitted to labor and delivery with contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the practical nurse (PN) hears a baby crying. Which action should the PN take first?

The practical nurse (PN) is assessing an older adult client with left-sided heart failure (HF). Which intervention is most important for the PN to implement?

In assessing the apical heart rate of an adult, in what order should the practical nurse (PN) perform the needed tasks?

The practical nurse (PN) notes that a client has truncal obesity, a moon face, and a buffalo hump. The PN should question the client about recent use of which type of medication?

Exhibits The practical nurse (PN) has received report and is preparing to enter the room to assess the client. What personal protective equipment (PPE) should the PN don before entering the room? Select all that apply.

The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?