A client is not ready for sleep and asks the nurse to leave the sleeping pill at the bedside. What is the most appropriate action for the nurse to take?

Leave the pill as requested

Have the client take it at this time or not at all

Tell the client to call the nurse when ready for the medication

Leave the pill as requested and check back in half an hour to be sure that the pill the medication was taken

Answer and Explanation

The Correct Answer is C

A. Leave the pill as requested: Leaving medications at the bedside is a violation of safety standards and institutional policy. It poses a significant risk for medication errors, accidental ingestion by others, or the client forgetting to take it. The nurse must personally witness the administration to ensure the "right patient" and "right dose" are confirmed.

B. Have the client take it at this time or not at all: This approach is unnecessarily rigid and ignores the principles of patient-centered care and autonomy. Sleep medications are most effective when the patient is physiologically and psychologically prepared for rest. Forcing immediate ingestion may lead to poor therapeutic outcomes or patient dissatisfaction with their care.

C. Tell the client to call the nurse when ready for the medication: This response respects the client's autonomy while adhering to strict medication safety protocols. It ensures the nurse is present to document the exact time of administration and monitor for immediate adverse effects. This practice maintains the chain of custody for controlled substances or sedative-hypnotics.

D. Leave the pill as requested and check back in half an hour to be sure that the pill the medication was taken: Even with a follow-up check, the nurse cannot definitively verify that the medication was swallowed rather than lost or hidden. Bedside storage remains a high-risk practice that circumvents required safety checks. Direct observation is the only acceptable method for confirming medication adherence.

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Correct Answer is C

Explanation

A. Hematocrit 46 %: This value falls within the normal physiological range for both adult males and females. Acetaminophen does not typically affect red blood cell volume or hemoglobin concentration. This lab result indicates normal oxygen-carrying capacity and hydration status rather than drug-induced toxicity or pathology.

B. Hemoglobin 14.6 g/dL: This result is well within the standard reference range and indicates no evidence of anemia or polycythemia. Chronic acetaminophen use is not associated with hematological suppression or gastrointestinal bleeding that would lower hemoglobin levels. It reflects a stable hematological profile for the client.

C. Elevated liver enzymes: Acetaminophen is primarily metabolized in the liver, where a small portion is converted into the toxic metabolite NAPQI. Chronic use or high doses can deplete glutathione stores, leading to hepatocyte necrosis. Elevated ALT and AST levels are the primary indicators of this drug-induced hepatic injury.

D. Elevated BUN and creatinine: These markers indicate renal function and are more typically associated with the use of non-steroidal anti-inflammatory drugs like ibuprofen. While massive acetaminophen overdose can cause secondary renal failure, chronic therapeutic use specifically targets the liver. Hepatic enzymes are the specific monitoring priority.

A. Unstageable injury B. Stage 1 pressure injury C. Stage 2 pressure injury D. Deep tissue pressure injury (DTI)

Correct Answer is B

Explanation

A. Unstageable injury: This classification applies when the true depth of tissue damage is obscured by slough or eschar. The presence of visible, intact skin with erythema allows for a definitive assessment. Because the wound bed is not covered by necrotic debris, this category is clinically inapplicable.

B. Stage 1 pressure injury: This stage is characterized by localized, non-blanchable redness over a bony prominence like the trochanter. The skin remains intact, though the area may be painful or different in temperature. It represents the earliest detectable stage of pressure-induced tissue ischemia and compromise.

C. Stage 2 pressure injury: This injury involves partial-thickness loss of the dermis, appearing as a shallow open ulcer or a serum-filled blister. The question specifies that the skin remains intact, which rules out any epidermal or dermal loss. It lacks the characteristic pink or red moist wound bed.

D. Deep tissue pressure injury (DTI): This manifests as persistent non-blanchable deep red, maroon, or purple discoloration, often feeling mushy or boggy. While it involves intact skin, the specific description of erythema fits a Stage 1 injury better. DTI suggests deeper underlying damage than simple superficial redness.

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A client is not ready for sleep and asks the nurse to leave the sleeping pill at the bedside. What is the most appropriate action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is monitoring lab results for a client who is receiving acetaminophen (Tylenol) for chronic pain. Which lab result(s) may be abnormal?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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