In preparing to discontinue a client's saline lock, the practical nurse (PN) notes that the client is receiving an antiplatelet medication. Which action should the PN implement?
Leave the saline lock in place and notify the charge nurse.
Plan to apply pressure over the site for several minutes.
Encourage the client to drink additional oral fluids.
Prepare a warm pack to apply after removing the lock
The Correct Answer is B
Antiplatelet medications, such as aspirin or clopidogrel, are prescribed to prevent the formation of blood clots by inhibiting platelet aggregation. These medications can increase the risk of bleeding or prolonged bleeding time. Therefore, when removing the saline lock, applying pressure over the site for several minutes helps to minimize the risk of bleeding and promote hemostasis.
A. Leaving the saline lock in place and notifying the charge nurse may not be necessary unless there are specific concerns or complications related to the client's condition.
C. Encouraging the client to drink additional oral fluids is not directly related to the discontinuation of the saline lock and the potential risk of bleeding associated with antiplatelet medication.
D. Preparing a warm pack to apply after removing the lock is not necessary for this situation. Warm packs are typically used for comfort or to promote circulation, but they are not directly related to the risk of bleeding associated with antiplatelet medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When a client refuses to look at their mastectomy incision and refuses to talk about it, the best response by the practical nurse (PN) is to respect the client's autonomy and validate their feelings. Option a) acknowledges the client's discomfort and provides reassurance that it is okay for them to decline to look or talk about the incision at the moment. It also offers support by letting the client know that the incision will be available for examination when they feel ready to do so.
Correct Answer is ["A","E"]
Explanation
A. This is a client care intervention that the PN can assign to the UAP. Transporting a urine culture sample to the laboratory is a routine and non-invasive task that does not require clinical judgment or skill. The UAP should follow the standard precautions and protocols for handling and labeling the specimen.
E. This is a client care intervention that the PN can assign to the UAP. Emptying the bedside drainage unit for a client with an indwelling urinary catheter is a routine and non-invasive task that does not require clinical judgment or skill. The UAP should follow the standard precautions and protocols for emptying, measuring, and recording the urine output.
B. This is not a client care intervention that the PN can assign to the UAP. Obtaining a post-voided residual (PVR) volume is a procedure that requires clinical judgment and skill, as it involves using a bladder scanner or catheterizing the client to measure the amount of urine left in the bladder after voiding. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.
C.This is not a client care intervention that the PN can assign to the UAP. Teaching the client with fluid restrictions how to measure urine output is an educational activity that requires clinical judgment and skill, as it involves assessing the client's learning needs, providing clear and accurate instructions, and evaluating the client's understanding and compliance. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.
D.This is not a client care intervention that the PN can assign to the UAP. Irrigating an indwelling urinary catheter for a client with bladder suspension is a procedure that requires clinical judgment and skill, as it involves inserting sterile fluid into the bladder through the catheter to flush out any clots, debris, or bacteria. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.
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