A nurse is caring for a patient who has cirrhosis of the liver.
The patient’s vital signs are as follows: Heart rate 101/min, Temperature 36 C (96.9 F), Respiratory rate 24/min, Blood pressure 82/58 mm Hg, Oxygen saturation 92%. Which of the following assessment findings require immediate follow-up? Select all that apply.

Choice A rationale

Amoxicillin-clavulanate is a type of antibiotic that falls under the class of penicillin antibiotics. If a patient is allergic to penicillin, they should not take amoxicillin as it belongs to the penicillin class of antibiotics and must be avoided. Therefore, if a nurse is caring for a child who is allergic to penicillin, they should verify a prescription for amoxicillin-clavulanate with the provider.

Choice B rationale

Gentamicin is an aminoglycoside antibiotic, not a penicillin antibiotic. Therefore, it is generally safe for use in patients with a penicillin allergy.

Choice C rationale

Erythromycin is a macrolide antibiotic, not a penicillin antibiotic. Therefore, it is generally safe for use in patients with a penicillin allergy.

Choice D rationale

Amphotericin B is an antifungal medication, not an antibiotic. Therefore, it is generally safe for use in patients with a penicillin allergy.

Step 1: Convert All Fluid Intake to Milliliters (mL)

To accurately record the patient's fluid intake, first, convert each fluid measurement to milliliters:

• 1 cup of coffee = 240 mL
• 4 oz of orange juice = 118.3 mL
• 3 oz of water = 88.7 mL
• 1 cup of flavored gelatin = 236.6 mL
• 1 cup of tea = 240 mL
• 5 oz of broth = 147.9 mL
• 3 oz of water (another serving) = 88.7 mL

Step 2: Calculate Total Fluid Intake

Add all the converted fluid amounts together:

• Total fluid intake = 240 mL (coffee) + 118.3 mL (orange juice) + 88.7 mL (water) + 236.6 mL (gelatin) + 240 mL (tea) + 147.9 mL (broth) + 88.7 mL (water) = 1,160.2 mL

Step 3: Round to the Nearest Whole Number

Round the total to the nearest whole number:

• Rounded total = 1,160 mL

The nurse should record 1,160 mL on the patient’s chart.