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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Correct Answer: D. Report the findings to the charge nurse.

Choice A rationale:

Monitoring the client's temperature hourly may be indicated if the client's condition deteriorates or if there are specific concerns about fever. However, the temperature of 99.8°F (37.66°C) is not significantly elevated and may not be the primary concern in this situation.

Choice B rationale:

Offering the client fluids frequently is a good nursing practice, but it is not the most important intervention in this case. The client's nonproductive cough and increased confusion need to be addressed and reported first.

Choice C rationale:

Providing care to moisten oral mucosa is important for maintaining oral health and preventing dryness and discomfort. However, it may not directly address the client's current symptoms of cough and confusion.

Choice D rationale:

Reporting the findings to the charge nurse is the most crucial intervention. The client's nonproductive cough and increased confusion may be indicative of an underlying issue, such as a respiratory infection or a change in neurological status. The charge nurse can initiate further assessments, notify the healthcare provider, and implement appropriate interventions to address the client's condition promptly. Timely reporting and communication are essential to ensure the client receives appropriate care.

A. Consecutive evening serum glucose greater than 260 mg/dL. B. States her feet are constantly cold along with feeling numb. C. Reports nausea in the morning but still able to eat breakfast. D. A wound on the ankle that starts to drain and becomes painful.

Correct Answer is A

Explanation

The correct answer is choice A. Consecutive evening serum glucose greater than 260 mg/dL.

Choice A rationale:

A consecutive evening serum glucose greater than 260 mg/dL indicates persistent hyperglycemia. Inadequate NPH insulin dosage may lead to consistently high blood glucose levels, which can result in various complications.

Choice B rationale:

The complaint of cold feet and numbness is not a specific indicator of inadequate insulin dosage. Neuropathy and circulation issues can occur with poorly controlled diabetes, but they are not solely indicative of inadequate insulin.

Choice C rationale:

Nausea in the morning, even with the ability to eat breakfast, does not necessarily point to inadequate insulin dosage. It could be due to various factors, including dietary choices or other medical conditions.

Choice D rationale:

The wound on the ankle that starts to drain and becomes painful is not a specific sign of inadequate insulin dosage. Poorly controlled diabetes can lead to delayed wound healing, but it does not necessarily indicate that the current insulin dosage is insufficient.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer is D

Explanation

An adult female client with type 1 diabetes mellitus is receiving NPH insulin 35 units each morning. Which finding should the practical nurse (PN) document as evidence that the amount of insulin is inadequate? (Reference Range: Glucose [0 to 50 years: less than 140 mg/dL or less than 7.8 mmo/L]).

Correct Answer is A

Explanation

The practical nurse (PN) is making a home visit to an older male adult who was recently diagnosed with Herpes zoster (shingles). The client reports the onset of severe burning pain along the right side of his trunk. What action should the PN take?

The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first?

During the past 30 days, an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of the daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the practical nurse (PN) take?

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

Which client information is most important for the practical nurse (PN) to consider when providing instructions to the unlicensed assistive personnel (UAP) about providing morning care to a postoperative client?

A client with a compound fracture of the left ankle is being discharged with a below-the-knee cast. Which instruction should the practical nurse (PN) provide to the client prior to discharge?

A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the practical nurse (PN) implement?