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 B
Explanation
Choice A rationale:
Ketorolac is a non-steroidal anti-inflammatory drug (NSAID) used for pain relief after surgery. However, it’s not typically administered every 3 hours. Overuse can lead to serious side effects.
Choice B rationale:
If the client’s pain level remains high after receiving ketorolac, administering an opioid medication like oxycodone may be appropriate.
Choice C rationale:
While acetaminophen can be used for pain relief, rectal administration is not typically the first choice for postoperative pain management.
Choice D rationale:
It’s inappropriate to label a patient as exhibiting drug-seeking behaviors simply because their reported pain level remains high after medication. Pain is subjective and should be addressed appropriately.
Correct Answer is C
Explanation
Choice A rationale:
While it’s important for the provider to be informed if the medication isn’t working, it’s premature to change the medication after only 6 days.
Choice B rationale:
Amitriptyline does not need to be taken on an empty stomach to be effective.
Choice C rationale:
Amitriptyline, a tricyclic antidepressant, often takes several weeks before a therapeutic effect is felt.
Choice D rationale:
Increasing the dose prematurely can lead to unnecessary side effects. It’s better to wait for the medication to take effect.
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