A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority?
Administer a PRN dose of acetaminophen.
Encourage the client to drink fluids.
Report the findings to the charge nurse.
Monitor the client's serum lipid levels.
The Correct Answer is C
This is the priority action by the practical nurse (PN) because it can help identify and prevent a potential adverse reaction to the medication. A client who is reaching saturation with medication means that the client has reached the maximum level of medication in the blood that can produce the desired therapeutic effect. However, this also means that the client is at a higher risk of developing toxicity or side effects from the medication.
The PN should report the findings of muscle soreness, fatigue, and warm skin to the charge nurse, as these may indicate signs of inflammation, infection, or allergic reaction to the medication. The PN should also monitor the client's vital signs, oxygen saturation, and laboratory values, and document the findings. The charge nurse should notify the health care provider and adjust the medication dosage or regimen as ordered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Inspecting the client's skin near the end of the bathing procedure allows the PN to directly assess the UAP's performance and evaluate the effectiveness of the bed bath. By observing the client's skin, the PN can determine if the UAP has properly cleaned and cared for the client's skin, identified any areas that may have been missed, and ensured that proper hygiene practices have been followed.
B. While verifying with the client that the bath was complete and thorough is important for client satisfaction, it may not provide a comprehensive evaluation of the UAP's performance. Clients may not be aware of all the necessary steps involved in a complete bed bath, so their perception may not accurately reflect the quality of the UAP's work.
C. Requesting the UAP to report and chart when the bath is complete is a useful documentation practice, but it does not provide a direct evaluation of the UAP's performance during the bed bath.
D. Asking another UAP to help the orientee may be helpful for providing guidance and support during the orientation process, but it does not provide a specific evaluation of the UAP's performance in completing the bed bath.
Correct Answer is A
Explanation
A. Washing the hair and skin daily with mild soap and warm water helps remove excess oil, dirt, and bacteria that can contribute to acne formation. Gentle cleansing is an appropriate first-line recommendation for adolescents with mild acne.
B. Eliminating specific foods such as chocolate or fried foods is not consistently supported by evidence as a primary treatment for acne. Diet may influence some individuals, but routine restriction of these foods is not a standard initial recommendation.
C. Squeezing or expressing blackheads can traumatize the skin, increase inflammation, and lead to scarring or infection. Harsh exfoliation may further irritate the skin and worsen acne.
D. Referral to a dermatologist may be necessary for severe or persistent acne. However, initial management for mild acne typically includes proper skin hygiene and over-the-counter measures before pursuing long-term prescription therapy.
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