A nurse is preparing to administer a new prescription for ampicillin 1.5g IV every 6 hr to a client who has an upper respiratory infection. The client also has a prescription for a sputum specimen for culture and sensitivity. Which of the following actions should the nurse plan to take? (Select all that apply.)

Verify the prescription.

Administer the medication at 1000, 1400, 1800, and 2200.

Assess the client for an allergy to penicillin

Document giving the medications

Obtain a sputum for culture and sensitivity

Answer and Explanation

Correct Answer : A,C,D,E

The nurse should plan to take the following actions:

A.Verify the prescription: Before administering any medication, the nurse must verify the prescription to ensure accuracy, appropriateness, and that it matches the provider's order.

Regarding option B, administering the medication at 1000, 1400, 1800, and 2200 may not be appropriate. The prescription states that ampicillin should be administered every 6 hours. The nurse should administer the medication at equally spaced intervals throughout the day. If the medication is prescribed every 6 hours, the appropriate administration times would be 0600, 1200, 1800, and 2400. However, the question does not provide sufficient information to determine the exact administration times, so option B cannot be definitively selected.

C. Assess the client for an allergy to penicillin: Since ampicillin is a penicillin-class antibiotic, it is essential for the nurse to assess the client for any history of allergies to penicillin or other beta-lactam antibiotics. A penicillin allergy could lead to a severe allergic reaction, so it is crucial to identify any potential allergies before administering the medication.

D. Document giving the medications: After administering the ampicillin, the nurse should document the administration in the client's medical record, including the time, dose, route, and any relevant observations or assessments.

E. Obtain a sputum for culture and sensitivity: The client's new prescription for ampicillin may be related to an infection. To ensure appropriate and effective treatment, obtaining a sputum specimen for culture and sensitivity is necessary. This will help identify the specific bacteria causing the respiratory infection and determine which antibiotics will be most effective in treating it.

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Correct Answer is C

Explanation

The nurse should expect angioedema as one of the manifestations of anaphylaxis in a client experiencing an allergic reaction to an antibiotic. Angioedema is a severe swelling that occurs beneath the skin, typically affecting the face, lips, tongue, throat, or other body parts. It is a result of the release of histamine and other inflammatory mediators in response to the allergen.

Anaphylaxis is a life-threatening allergic reaction that can occur rapidly and affect multiple body systems. In addition to angioedema, other common manifestations of anaphylaxis include:

Difficulty breathing or wheezing due to bronchospasm
Hives or urticaria, which are itchy raised skin rashes
Severe itching or tingling sensation
Rapid and weak pulse
Low blood pressure leading to hypotension
Nausea, vomiting, or diarrhea
Feeling of impending doom or anxiety

Let's go through the other options:

A. Hypertonic reflexes: This is not a manifestation of anaphylaxis. "Hypertonic reflexes" are not typically associated with allergic reactions or anaphylaxis. Hypertonic reflexes refer to increased muscle tone, but they are not part of the usual presentation of anaphylaxis.

B. Increase in systolic blood pressure: Anaphylaxis usually leads to a decrease in blood pressure rather than an increase. The decrease in blood pressure can be severe and result in shock, which is a life-threatening condition.

D. Urinary retention: Urinary retention is not a common manifestation of anaphylaxis. Anaphylaxis primarily affects the respiratory and circulatory systems, leading to airway constriction, difficulty breathing, and cardiovascular collapse. Urinary retention is not directly related to the pathophysiology of anaphylaxis.

A. Hypoglycemia B. Hyperreflexia C. Osteoporosis D. Inflammatory bowel disease

Correct Answer is C

Explanation

The nurse should monitor the client receiving long-term treatment with oral doses of prednisone for the development of osteoporosis. Prednisone is a corticosteroid medication that can lead to decreased bone density and increase the risk of fractures. Prolonged use of prednisone can interfere with calcium absorption and increase bone resorption, leading to osteoporosis.

Hypoglycemia (A) is not a common adverse effect of prednisone. In fact, prednisone can cause hyperglycemia and increase the risk of developing diabetes.

Hyperreflexia (B) is not typically associated with prednisone use. Hyperreflexia is an exaggerated reflex response and is not a common adverse effect of corticosteroid therapy.

Inflammatory bowel disease (D) is not an adverse effect of prednisone. In fact, prednisone is often used as a treatment for inflammatory bowel disease to reduce inflammation and symptoms.

Therefore, the nurse should primarily monitor the client for the development of osteoporosis when receiving long-term treatment with oral doses of prednisone.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing an anaphylactic reaction to an antibiotic. Which of the following manifestations of anaphylaxis should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving long-term treatment with oral doses of prednisone. For which of the following adverse effects should the nurse monitor?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving heparin by continuous IV infusion for treatment of venous thrombosis. Which of the following laboratory values should the nurse monitor for in order to titrate the heparin dose?

A nurse is reviewing the medical record of a client who has a new prescription for verapamil. Which of the following findings in the client's medical record should the nurse identify as a contraindication for the administration of verapamil?

A nurse is providing teaching to a client who has chronic rheumatoid arthritis and a new prescription for hydroxychloroquine. The nurse should instruct the client to obtain which of the following diagnostic studies routinely?

A nurse is caring for a client who is receiving meperidine. Which of the following is the nurse's priority assessment before administering the medication?

A nurse is caring for a client who is starting to take aspirin 81 mg daily. Which of the following findings should the nurse identify as a risk factor for the client's development of an aspirin-induced ulcer?

A nurse is caring for a client who has congestive heart failure and is taking captopril. Which of the following laboratory values should the nurse report to the provider as a potential adverse effect of captopril?

A nurse accidently removes celecoxib from an automated medication dispensing system (AMDS) instead of citalopram and almost administers the wrong medication to a client. Which of the following actions should the nurse take?

A nurse is reviewing the medication list of a client who has a new prescription for clopidogrel after undergoing coronary artery stenting. Which of the following findings should the nurse report to the provider?