During morning rounds, a practical nurse (PN) evaluates an adult client being treated for … — NCLEX-PN

During morning rounds, a practical nurse (PN) evaluates an adult client being treated for severe chronic obstructive pulmonary disease (COPD) with scheduled oral theophylline. The client complains of new-onset nausea and an inability to rest. Vital signs reveal a heart rate of $112\text{ beats/min}$ . The morning laboratory report shows a serum theophylline concentration of $24\text{ mcg/mL}$ . What is the most appropriate action for the PN to take?

Hold the next dose of theophylline and immediately notify the registered nurse of the assessment findings.Cevap
B
Provide a light snack to relieve the client's nausea and administer the scheduled dose.
C
Independently decrease the medication dose by half to prevent further cardiac stimulation.
D
Administer the scheduled dose as the laboratory result falls within the target range for COPD.

Cevap

The PN must withhold the medication and report the findings to the registered nurse because the client is exhibiting signs of theophylline toxicity.

The normal therapeutic range for serum theophylline is typically

10

20\text{ mcg/mL}

. A level of

24\text{ mcg/mL}

, combined with clinical symptoms such as nausea, restlessness, and tachycardia, strongly indicates theophylline toxicity. The most appropriate and safe action within the practical nurse's scope of practice is to withhold the medication to prevent further toxicity and immediately report these critical findings to the registered nurse for further medical orders.

Adım Adım Çözüm

Evaluate the client's assessment data and laboratory values.

The client has a heart rate of

112\text{ beats/min}

, nausea, restlessness, and a theophylline level of

24\text{ mcg/mL}

Gathering and interpreting clinical data is necessary before safely administering any pharmacological therapy.

Compare the theophylline level to the established therapeutic range.

The result of

24\text{ mcg/mL}

is recognized as toxic.

The expected therapeutic range for serum theophylline is typically

10

20\text{ mcg/mL}

. Levels above

20\text{ mcg/mL}

place the client at risk for dangerous arrhythmias and seizures.

Determine the appropriate nursing intervention based on the practical nurse scope of practice.

The nurse must withhold the toxic dose and escalate the critical findings to the supervising registered nurse or healthcare provider.

Ensuring client safety requires withholding harmful medications, and practical nurses must collaborate with RNs when a client's condition deteriorates or requires medical intervention.

Anahtar Kavram

Medication Safety: Identifying and Responding to Theophylline Toxicity

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