A male client tells the practical nurse (PN) that he usually takes a smaller white tablet, not the large blue tablet that the PN gives him. Which action should the-PN implement first?

Check the medical record to verify the medication's name and strength.

Reassure the client that the blue tablet is the correct medication.

Explain that the tablets are from different manufacturers

Withhold the medication and notify the healthcare provider.

Answer and Explanation

The Correct Answer is A

A. Check the medical record to verify the medication's name and strength: The first action is to verify the medication against the medical record to ensure it is the correct drug, dose, and formulation. This prioritizes patient safety by confirming accuracy before administration, preventing possible medication errors.
B. Reassure the client that the blue tablet is the correct medication: Reassuring the client without verifying the medication could risk administering the wrong drug. Even if the nurse believes the medication is correct, professional standards require verification when a discrepancy is noted by the patient.
C. Explain that the tablets are from different manufacturers: Differences in tablet appearance between manufacturers are common, but assuming this without verifying could result in a serious medication error. Visual differences should always be validated against the order and pharmacy records first.
D. Withhold the medication and notify the healthcare provider: Withholding the medication and notifying the healthcare provider may be appropriate if verification reveals a problem. However, the first step is to check the medical record to determine if the medication given matches the prescribed drug and dose.

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Correct Answer is A

Explanation

A. Alteration in comfort: Restlessness, shallow breathing, and clenching teeth are strong indicators of discomfort or pain, especially in a client with aphasia who cannot verbalize needs. Assessing for pain or other sources of distress is the priority to address the client’s immediate comfort and prevent further deterioration.
B. Deficit in diversional activity: While limited activity can impact emotional health, signs like restlessness and physical tension suggest an immediate physical problem rather than boredom or inactivity. Comfort issues must be addressed first before considering diversional needs.
C. Elevated blood pressure: Stroke patients are at risk for hypertension, but restlessness and shallow respirations alone do not directly indicate elevated blood pressure. Blood pressure may rise secondary to pain or distress, but comfort assessment is still the initial focus.
D. Change in blood glucose level: Blood glucose fluctuations can cause changes in mental status or energy levels, but the client’s symptoms of clenching teeth and shallow breathing more strongly point toward discomfort or pain rather than hypoglycemia or hyperglycemia.

A. Check for external rectal hemorrhoids. B. Note inflammation in the perineal area. C. Observe for signs of fluid volume deficit. D. Determine any changes in sleep patterns.

Correct Answer is C

Explanation

A. Check for external rectal hemorrhoids: Hemorrhoids may cause discomfort during diarrhea, but they are not the most urgent concern. The primary issue with severe diarrhea is the risk of dehydration and electrolyte imbalance, which can become life-threatening.
B. Note inflammation in the perineal area: While important for skin care and comfort, perineal inflammation does not pose the immediate systemic risk that fluid volume deficit does. Skin assessment can be addressed after ensuring the client's vital signs and hydration status are stable.
C. Observe for signs of fluid volume deficit: Severe diarrhea leads to significant fluid and electrolyte losses. Signs such as hypotension, tachycardia, dry mucous membranes, and decreased urine output indicate fluid volume deficit, which requires urgent intervention to prevent shock and organ dysfunction.
D. Determine any changes in sleep patterns: Sleep disturbances can occur with illness but are not as immediately critical to assess as fluid and electrolyte status. Identifying fluid volume deficit must be prioritized to prevent rapid clinical deterioration.

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A male client tells the practical nurse (PN) that he usually takes a smaller white tablet, not the large blue tablet that the PN gives him. Which action should the-PN implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is providing care for a client with a history of a stroke and who has aphasia. The client is exhibiting restlessness, shallow respirations and is clenching teeth. Which problem should the PN assess further?

Correct Answer is A

Explanation

When caring for a client with severe diarrhea, which focused assessment is most important for the practical nurse (PN) to complete before reporting to the charge nurse?

Correct Answer is C

Explanation

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