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.

Answer and Explanation

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.

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Correct Answer is ["A","B","D"]

Explanation

The practical nurse (PN) should include the following actions when assessing a client for signs and symptoms of fluid volume excess:

Palpate the rate and volume of the pulse: Fluid volume excess can lead to an increased pulse rate and bounding pulse due to the increased blood volume.
Measure body weight at the same time daily: Monitoring daily weights can help identify fluid retention or weight gain, which can be indicative of fluid volume excess.
Observe the color and amount of urine: Changes in urine color and output can provide information about kidney function and fluid balance. In fluid volume excess, urine output may be increased and urine may appear pale or diluted.

The following options are incorrect:

Check fingernails for the presence of clubbing: Clubbing of the fingernails is not directly related to fluid volume excess. It is a finding commonly associated with chronic respiratory conditions and certain cardiac disorders.
Compare muscle strength of both arms: Assessing muscle strength is not directly related to fluid volume excess. It is more relevant when evaluating neurological or musculoskeletal conditions.

A. Wrap the bag in place for comfort. B. Secure a protective cover over the bag. C. Give directions to leave the pack in place. D. Fill the ice pack with crushed ice

Correct Answer is B

Explanation

The most important intervention for the practical nurse (PN) to implement when applying an ice pack to a client is to secure a protective cover over the bag. This is essential to protect the client's skin from direct contact with the ice pack, which can cause tissue damage, frostbite, or discomfort.
Securing a protective cover, such as a thin cloth or towel, between the ice pack and the client's skin helps to create a barrier and prevent excessive cold exposure. It allows for the therapeutic benefits of the ice pack, such as reducing swelling and pain, while minimizing the risk of skin damage.
Incorrect:

A. While wrapping the bag in place for comfort is important, it is not the most critical intervention compared to ensuring the protection of the client's skin.
C. Giving directions to leave the pack in place is a general instruction for the client to follow the prescribed treatment, but it does not specifically address the importance of using a protective cover.
D. The type of ice used, whether crushed or cubed, may vary based on availability and preference, but it does not take precedence over the need to protect the client's skin with a cover.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of fluid volume excess? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

Which intervention is the most important for the practical nurse (PN) to implement when applying an ice pack to a client?

Correct Answer is B

Explanation

The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) take in this situation?

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56. The practical nurse (PN) is caring for a client who has a tracheostomy tube. After donning sterile gloves, in which sequence should the PN should implement these interventions? (Arrange from the first action on top to last on the bottom.)

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The mother of an 8-year-old boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment finding should the PN note as the most significant indicator of possible child abuse?

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