A nurse has received change-of-shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first?
A client who had a blood glucose reading at 0650 of 70 mg/dL after receiving 50% dextrose for a hypoglycemic episode
A client who has pulled out the peripheral IV catheter and is scheduled to receive a dose of famotidine at 0800
A client who was admitted for chest pain and is reporting a new onset of indigestion
A client who has pneumonia and was treated for a temperature of 38.9° C (102° F) at 0400
The Correct Answer is C
A. A blood glucose reading of 70 mg/dL is low but stable, and the client has already received treatment.
B. Pulling out a peripheral IV catheter is concerning but not immediately life-threatening.
C. New onset of indigestion in a client admitted for chest pain could indicate a cardiac event and requires immediate assessment.
D. A temperature of 38.9°C (102°F) in a client with pneumonia needs monitoring but is not as urgent as potential cardiac issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Reviewing at the nurses' station ensures understanding but is not the final check.
B. Documentation occurs after administration and is not part of the final check.
C. Checking the medication in the area where it was obtained is important but not the final check.
D. Performing the final check at the client's bedside before administration ensures the correct medication is given to the correct client, preventing medication errors.
Correct Answer is ["A","B","D","F"]
Explanation
A. Peripheral IV in large vein
Vancomycin should be administered through a large-bore IV to minimize the risk of complications such as phlebitis and to ensure effective drug delivery. This is a key factor in safely administering the medication.
B. Dosage in safe range
Confirming that the dosage is within the safe range ensures that the medication is administered at an effective but non-toxic level. Proper dosing is essential for achieving therapeutic effects without causing harm.
C. No known allergies
Ensuring that the client has no known allergies to vancomycin is critical to prevent allergic reactions. This step is necessary for the safe administration of the antibiotic.
D. Potassium 4.4 mEq/L (4.4 mmol/L)
While normal potassium levels are important for overall health, they do not specifically indicate the safety of vancomycin administration. Other factors such as IV access and dosage are more directly related to the safety of vancomycin.
E. Used for prophylaxis
Vancomycin is used for endocarditis prophylaxis in this case, which aligns with the clinical guidelines for preventing infections. Understanding the purpose of the medication supports its appropriate use in the client’s care.
F. Blood urea nitrogen 17 mg/dL (6.07 mmol/L)
An elevated BUN level might indicate renal impairment, which could affect vancomycin metabolism. However, this level alone does not directly address the immediate safety of administering the antibiotic compared to other factors like IV access and dosage.
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