Exhibits

A nurse is collecting data from a client who has pneumonia and a prescription for cefazolin. Which of the following findings should the nurse report to the provider prior to administering the initial dose? (Cliick on the exhibit tabs for additional information about t three tabs that contain separate categories of data.)

Temperature

WBC count

Allergies

Chest x-ray

Answer and Explanation

The Correct Answer is C

Rationale:

• Temperature: An elevated temperature of 39.3° C is consistent with an active infection like pneumonia. This finding supports the need for antibiotic treatment and does not delay administration unless linked to an adverse drug reaction.

• WBC count: A WBC count of 16,000/mm³ indicates leukocytosis, which is expected in bacterial pneumonia. It confirms infection and the need for antibiotics, not a reason to withhold cefazolin.

• Allergies: The client has a documented allergy to penicillin, which is critical because cefazolin is a cephalosporin. Cephalosporins share a similar beta-lactam structure and can cross-react in clients with penicillin allergies, increasing the risk of anaphylaxis. Reporting this ensures safe prescribing and prevents a life-threatening hypersensitivity reaction.

• Chest x-ray: The left lower lobe density confirms pneumonia. This imaging supports the clinical decision to administer antibiotics and does not warrant withholding the prescribed medication.

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Correct Answer is ["B","D","E"]

Explanation

Rationale:

• Heart rate of 110/min indicates tachycardia, which can be an early sign of hypovolemia, sepsis, or pain and should be followed up due to the recent report of a "popping" sound and increased drainage.
• Abdominal dressing now has a large amount of serosanguinous drainage, suggesting possible wound dehiscence or evisceration, which is a surgical emergency requiring prompt evaluation.
• Blood pressure of 98/50 mm Hg indicates hypotension, which, along with tachycardia and fever, suggests potential sepsis or internal fluid loss and needs immediate intervention.

• Pedal pulses are 2+, which is within normal limits and unchanged from Day 1, indicating adequate peripheral perfusion at present.
• Oxygen saturation at 95% on room air is within normal limits and not significantly changed from previous levels, requiring no urgent action.
• Breath sounds are still clear and present bilaterally, indicating no respiratory compromise or pulmonary complication at this time.

A. "The client's partner visited earlier today for 2 hours." B. "The client received the prescribed antibiotic every 8 hours." C. "The client's mother died 4 years ago from breast cancer." D. "The client reports pain is reduced when he is positioned on his side.”

Correct Answer is D

Explanation

Rationale:

A. "The client's partner visited earlier today for 2 hours.": While documenting visitors can be relevant in certain psychosocial or safety contexts, this detail is not critical to clinical decision-making or continuity of care during shift handoff.

B. "The client received the prescribed antibiotic every 8 hours.": Routine administration of scheduled medications does not need to be reported unless there are concerns like adverse reactions, missed doses, or changes in therapy. Simply stating adherence to the schedule adds little value to clinical communication.

C. "The client's mother died 4 years ago from breast cancer.": Past family history may be relevant to the medical record, but it does not impact immediate clinical care or require prioritization during a shift change report unless it is directly influencing current treatment decisions.

D. "The client reports pain is reduced when he is positioned on his side.”: This is current, subjective, and actionable information that informs the incoming nurse about effective pain management strategies and contributes to patient comfort and care planning.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client Exhibits Select the 3 findings that require immediate follow-up.

Correct Answer is ["B","D","E"]

Explanation

A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

Correct Answer is D

Explanation

A nurse is preparing to administer an antibiotic to a client who has pneumonia. After confirming that the client's assigned identification number matches the medication administration record, the nurse should use which of the following as a second identifier?

A nurse is assisting in the care of an older adult client who has COPD and is receiving albuterol treatments and 20 mg of prednisone twice daily. The client asks why the nurse is checking his blood glucose level. Which of the following responses should the nurse make?

A nurse is reinforcing teaching with a client who has a new prescription for enoxaparin. The nurse should identify which of the following over-the- counter products as unsafe for use with enoxaparin?

A nurse is reinforcing teaching with the guardian of a newborn about measures that can be taken to minimize the risk of sudden unexpected infant death (SUID). Which of the following instructions should the nurse include in the teaching?

A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7-month-old infant who is febrile. Available is ibuprofen 50 mg/1.25 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is unfamiliar with a medication they are preparing to administer to a client. Which of the following actions should the nurse take?

A nurse is collecting data from a client who is taking an oral contraceptive. Which of the following findings is a contraindication for the use of oral contraceptives?