A nurse is collecting data from a client who is receiving vancomycin for a Clostridium difficile infection.
Which of the following findings is the priority for the nurse to report to the provider?
Two loose stools in the past 24 hr.
WBC 11,000/mm³.
Heart rate 104/min.
Creatinine 3.1 mg/dL.
The Correct Answer is D
Choice A rationale:
Two loose stools in the past 24 hours could be a symptom of Clostridioides difficile infection, but it’s not necessarily a priority finding. The infection can cause diarrhea, but it’s not life-threatening.
Choice B rationale:
A WBC count of 11,000/mm³ is slightly elevated, indicating a possible infection. However, it’s not necessarily a priority finding as it’s not significantly high.
Choice C rationale:
A heart rate of 104/min is slightly elevated, indicating possible stress or anxiety. However, it’s not necessarily a priority finding as it’s not significantly high.
Choice D rationale:
Creatinine level of 3.1 mg/dL is significantly high, indicating possible kidney damage, which can be a side effect of vancomycin treatment. This should be reported to the provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Montelukast does not improve peripheral vasodilation. It is a leukotriene receptor antagonist used to reduce inflammation in the airways.
Choice B rationale:
Montelukast does not increase the WBC count. It works by reducing inflammation in the airways, not by affecting the immune system.
Choice C rationale:
Montelukast does not neutralize gastric acid. It is not an antacid or proton pump inhibitor, it is used to reduce inflammation in the airways.
Choice D rationale:
Montelukast reduces bronchial inflammation. It helps to prevent asthma attacks and exercise-induced bronchoconstriction by reducing inflammation in the airways.
Correct Answer is D
Explanation
Choice A rationale:
While reminding the client to change positions slowly is important to prevent orthostatic hypotension, it is not the priority before administering furosemide.
Choice B rationale:
Preparing the client’s medication is an important step, but it should be done after reviewing the client’s electrolyte levels.
Choice C rationale:
Recording the client’s urinary output is important when administering furosemide, a diuretic, but it is not the priority action.
Choice D rationale:
Reviewing the client’s electrolyte levels is crucial before administering furosemide because it can cause electrolyte imbalances, including low potassium levels, which can lead to serious cardiac complications.
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