The practical nurse (PN) receives prescriptions from the healthcare provider. Click to highlight the 3 prescriptions that the PN should perform right away.

A. Acetaminophen 600 mg PO every 6 hours PRN for pain or temperature greater than 100° F (37.7° C)
B. Contact precautions
C. Vancomycin 500 mg IV piggyback every 6 hours
D. Place peripheral IV
E. Change turban dressing by cleansing with sterile water, patting dry, applying dry gauze over incision, and wrapping head with kerlix
F. Strict intake and output
G. Clear liquid diet

Acetaminophen 600 mg PO every 6 hours PRN for pain or temperature greater than 100° F (37.7° C)

Contact precautions

Vancomycin 500 mg IV piggyback every 6 hours

Place peripheral IV

Change turban dressing by cleansing with sterile water, patting dry, applying dry gauze over incision, and wrapping head with kerlix

Strict intake and output

Clear liquid diet

Answer and Explanation

The Correct Answer is ["B","C","E"]

A. Acetaminophen 600 mg PO every 6 hours PRN for pain or temperature greater than 100° F (37.7° C)
While acetaminophen is necessary for managing fever or pain, it is a PRN medication, meaning it is only given based on specific symptoms (temperature greater than 100°F or pain). Immediate administration is not required unless the client’s symptoms meet these criteria.
B. Contact precautions
Contact precautions are crucial for preventing the spread of MRSA, a highly contagious pathogen. Immediate implementation is necessary to protect both the client and others in the healthcare setting from infection.
C. Vancomycin 500 mg IV piggyback every 6 hours
Vancomycin is prescribed to treat the MRSA infection. It should be administered as ordered to manage the infection effectively and prevent complications from the surgical site infection.
D. Place peripheral IV
The peripheral IV has already been placed, as indicated by the notes. This action would have been necessary before starting the IV medication orders but is not an immediate task at this time.
E. Change turban dressing by cleansing with sterile water, patting dry, applying dry gauze over incision, and wrapping head with kerlix
Changing the turban dressing is necessary to manage the infection at the surgical site. This must be done according to the prescribed procedure to maintain sterile conditions and support healing.
F. Strict intake and output
While monitoring intake and output is important, it does not need to be done immediately but should be started as per the order to monitor the client’s fluid balance over time.
G. Clear liquid diet
Initiating a clear liquid diet is important for nutritional support, but it does not need to be started immediately. It is part of the general care plan but does not have the same urgency as infection control and medication administration

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Administering acetaminophen can help reduce fever and discomfort but does not directly address the respiratory distress indicated by tachypnea and stridor.
B. Monitoring the child's oxygen saturation level via pulse oximeter is essential to assess the severity of the respiratory distress. It provides critical information on the child's oxygenation status and helps guide further interventions.
C. Encouraging the child to drink adequate amounts of cool, clear liquids is beneficial for hydration but does not directly address the acute respiratory symptoms of irritability, tachypnea, and stridor.
D. Instructing the mother to play with the child for stimulation and distraction may help alleviate irritability but does not address the underlying respiratory distress, which requires immediate attention.

A. Fall precautions. B. Aspiration precautions. C. Reorientation cues. D. Bowel training.

Correct Answer is A

Explanation

A. Implementing fall precautions is the most important intervention for a client with Parkinson’s disease experiencing decreased postural reflexes, rigidity, and gait issues. These symptoms significantly increase the risk of falls, so fall precautions are crucial for preventing injury.
B. Aspiration precautions are important for many clients, but they are less immediately relevant in this context compared to fall prevention. The symptoms listed do not directly indicate a high risk of aspiration.
C. Reorientation cues may be necessary for clients with cognitive issues but are not the primary concern for managing motor symptoms like those listed. The focus here should be on physical safety rather than cognitive orientation.
D. Bowel training is a useful intervention for managing bowel function but is not directly related to the acute risks of fall and gait disturbances associated with Parkinson’s disease.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?

Correct Answer is B

Explanation

A client with Parkinson's disease is experiencing decreased postural reflexes, rigidity, retropulsive gait, and shuffling. Which intervention is most important for the practical nurse (PN) to implement?

Correct Answer is A

Explanation

A client who is experiencing paralysis of the left arm curses at the practical nurse (PN) and throws a hairbrush against the wall using the right arm. How should the PN respond?

The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) using an alcohol-based cleanser after delivering a client's breakfast tray to the room. The UAP rubs both hands thoroughly for 2 minutes while standing at the door to the client's room. Which action should the PN take?

Exhibits Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. When the laboratory results are available, the practical nurse (PN) would expect the child to have dropdown related to dropdown during the submersion.

An older adult client who had a colon resection 8 days ago is straining at stool. The practical nurse (PN) observes sudden spillage of serosanguinous drainage from the client's wound followed by appearance of bowel on the skin. Which complication has occurred?

Exhibits What factors are important in determining level of hypoxemia that the child may have experienced during the submersion? Select all that apply.

The practical nurse (PN) views the mid-line episiotomy of a client who reports pain in her stitches. Which action should the PN take first?

The practical nurse (PN) plans to use distraction techniques while a client undergoes a brief painful procedure. Which action should the PN implement during the procedure?