The practical nurse (PN) is preparing a client for discharge who receives a prescription for oral prednisone to treat a severe allergic reaction. Which teaching about medication administration should the PN reinforce?

The practical nurse (PN) who hears adventitious breath sounds while auscultating the lungs of an older adult who is receiving an IV of 5% dextrose in water (DW) at 100 mL/hour should report the findings to the charge nurse.

Adventitious breath sounds can be indicative of respiratory problems such as fluid accumulation or infection in the lungs. In this case, it is important for the PN to report the findings to the charge nurse to ensure appropriate action is taken to assess and manage the client's respiratory status.

incorrect:

B- Reviewing the last balance of intake and output is important for overall assessment but may not directly address the concern of adventitious breath sounds. It can provide additional information about the client's fluid balance, but it is not the next immediate action in response to the abnormal lung sounds.

C- Slowing the DSW infusion rate to 50 mL/hour is not the most appropriate action to take based solely on the presence of adventitious breath sounds. The abnormal lung sounds may be an indication of an underlying respiratory issue that needs further evaluation and intervention.

Adjusting the infusion rate without a comprehensive assessment and appropriate medical orders could potentially overlook the underlying cause.

D- Documenting the findings and monitoring the client is necessary, but it should not be the sole action taken. Reporting the findings to the charge nurse is crucial to ensure prompt assessment and appropriate intervention.

A. "Are you planning to obey the voices?" – This question is crucial as it assesses the immediate risk of harm to the client or others. Determining if the client intends to follow commands from hallucinations provides insight into potential danger, ensuring safety is prioritized.

B. "Have you taken any hallucinogens?" – While drug use can contribute to hallucinations, asking about substance use is less urgent than assessing potential harm from the voices. Immediate safety takes precedence over exploring potential causes at this stage.

C. "When did these voices begin?" – Knowing when the symptoms started is relevant for understanding the history of the hallucinations but is secondary to determining if the client intends to act on any commands from the voices, as safety is the first priority.

D. "Do you believe the voices are real?" – This question helps assess the client’s insight into the hallucinations but is not as critical as assessing the immediate risk of harm by determining if the client plans to follow any commands from the voices.