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

A. Throw away soiled clothing.
Not Applicable
Throwing away soiled clothing does not address the issue of elder mistreatment and may not be relevant to the investigation of abuse or neglect. Instead, the focus should be on assessing the situation, documenting evidence, and ensuring the client’s safety. The PN’s role includes observing signs of mistreatment and reporting them, not managing personal items.
B. Report findings to Adult Protective Services.
Applicable
Reporting to Adult Protective Services is crucial for initiating a formal investigation into suspected elder mistreatment. These agencies are equipped to handle allegations of abuse and neglect through professional investigation and intervention. This step ensures that the client receives the appropriate protection and that any mistreatment is addressed legally.
C. Complete a comprehensive history.
Applicable
A comprehensive history helps the PN understand the client’s background, current living conditions, and any potential patterns of mistreatment. This information is essential for identifying signs of abuse or neglect and for making an informed report to the appropriate authorities. It also assists in documenting the client’s experiences and concerns.
D. Perform a thorough physical assessment.
Applicable
A thorough physical assessment allows the PN to identify and document signs of physical abuse or neglect, such as injuries or unsanitary conditions. This documentation is important for supporting the findings in the report to Adult Protective Services and for planning further interventions. The assessment provides evidence of mistreatment and helps in evaluating the client’s overall well-being.
E. Question the client in front of the suspected abuser.
Not Applicable
Questioning the client in front of the suspected abuser can be unsafe and may lead to further mistreatment of the client. It is important to conduct these discussions privately to protect the client and obtain accurate information. The PN should gather information discreetly and report findings to the authorities without risking the client’s safety.
F. Develop a safety plan.
Applicable
Developing a safety plan is essential for ensuring the client’s immediate safety and preparing for any potential risks of mistreatment. This plan addresses how the client can be protected from further harm and outlines steps for seeking help if needed. It is a proactive measure to safeguard the client’s well-being.
G. Take photographs to document the abuse or neglect.
Applicable
Photographs serve as objective evidence of abuse or neglect, which is valuable for investigations by Adult Protective Services. Documenting visual evidence helps in assessing the severity of the mistreatment and supports the report made to authorities. It provides a clear record of conditions that might otherwise be subjective or difficult to convey.
H. Confront the abuser about concerning actions.
Not Applicable
Confronting the abuser can escalate the situation and put the client at further risk of mistreatment. This action should be handled by professionals trained to manage such situations. The PN’s role is to observe, document, and report findings rather than directly addressing the suspected abuser

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