A client who is receiving a statin 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 takes priority?

Encourage the client to drink fluids.

Monitor the client's serum lipid levels.

Report the findings to the charge nurse.

Administer a PRN dose of acetaminophen.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Report the findings to the charge nurse. Choice A rationale:

Encouraging the client to drink fluids is not the priority in this situation. While hydration is important, the client's symptoms of muscle soreness, fatigue, and warm skin might indicate a potential adverse reaction to the statin medication, which requires immediate attention.

Choice B rationale:

Monitoring the client's serum lipid levels is not the priority at this moment. The client's current symptoms suggest a possible adverse reaction to the statin medication, and waiting for lipid level results may delay necessary interventions.

Choice C rationale:

Reporting the findings to the charge nurse is the priority action. The client's symptoms could be signs of rhabdomyolysis, a severe and potentially life-threatening condition where muscle breakdown releases toxic substances into the bloodstream. The charge nurse needs to be informed promptly so that appropriate interventions can be initiated.

Choice D rationale:

Administering a PRN dose of acetaminophen is not the priority in this situation. Acetaminophen may help with pain relief, but it will not address the potential underlying issue of muscle soreness and fatigue related to the statin medication.

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Correct Answer is ["C"]

Explanation

The correct answer is choice C. Initiation of changes in infection control measures.

Choice A rationale:

Limiting the client’s fluid intake to avoid hemodilution is not relevant to managing a decreased ANC. Hemodilution is not a concern in this context, and fluid intake should generally be maintained to support overall health.

Choice B rationale:

Avoiding exposure to cold temperatures is not directly related to managing a decreased ANC. While keeping the client comfortable is important, it does not address the increased risk of infection associated with neutropenia.

Choice C rationale:

Initiation of changes in infection control measures is crucial when a client’s ANC decreases. Neutropenia increases the risk of infections, so enhanced infection control practices, such as strict hand hygiene, use of protective isolation, and monitoring for signs of infection, are essential to protect the client.

Choice D rationale:

Increasing the client’s dietary servings of fruits and vegetables is generally beneficial for overall health but does not specifically address the immediate risks associated with a decreased ANC. In fact, certain fresh fruits and vegetables might need to be avoided if they pose a risk of introducing pathogens.

A. Catheterize the client for residual urine volume. B. Evaluate for normal involution, then massage the fundus. C. Measure the next voiding, then palpate the client's bladder. D. Obtain a specimen for urine culture and sensitivity.

Correct Answer is C

Explanation

Correct Answer: C. Measure the next voiding, then palpate the client's bladder.

Choice A rationale:

Catheterizing the client for residual urine volume is not necessary at this point because the woman has recently given birth, and frequent urination is common during the postpartum period. Additionally, catheterization poses risks of infection, so it should be reserved for situations where it is clinically indicated.

Choice B rationale:

Evaluating for normal involution and massaging the fundus is not relevant in this context. Fundal massage is performed after childbirth to ensure the uterus contracts and prevents excessive bleeding. The woman's concern is about frequent urination, which does not require fundal massage.

Choice C rationale:

Measuring the next voiding and palpating the client's bladder is the most appropriate action. The woman's increased frequency of urination could be due to postpartum diuresis, a normal physiological process where the body eliminates excess fluid accumulated during pregnancy. By measuring the next voiding and palpating the bladder, the nurse can assess for bladder distension or retention, which could be signs of a problem.

Choice D rationale:

Obtaining a specimen for urine culture and sensitivity is not indicated in this situation. There is no evidence to suggest that the woman has a urinary tract infection or other urinary issues that would warrant a urine culture at this time.

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A client who is receiving a statin 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 takes priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While receiving report for a client with carcinoma in situ of the left breast, the practical nurse (PN) reviews a pending lab report and notices the client's Absolute Neutrophil Count (ANC) has decreased. Which changes should the PN anticipate to be included in the client's plan of care?

Correct Answer is ["C"]

Explanation

A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?”. Which action should the practical nurse (PN) implement?

Correct Answer is C

Explanation

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