On admission, the healthcare provider prescribes a broad spectrum antibiotic for a client with a gram-negative infection. Before administering the first dose, it is most important for the nurse to implement which prescription?
Monitor for signs of sodium and fluid retention.
Wound and blood specimens for culture and sensitivity.
Complete blood count and serum electrolytes.
Irrigation and topical antibiotic application to wound area.
The Correct Answer is B
Choice A reason: Monitoring for signs of sodium and fluid retention is not relevant to this situation, as broad spectrum antibiotics do not affect sodium or fluid balance. Sodium and fluid retention may be caused by other conditions such as heart failure, kidney disease, or liver disease.
Choice B reason: Obtaining wound and blood specimens for culture and sensitivity is most important before administering the first dose of a broad spectrum antibiotic, as this can help identify the specific type and strain of bacteria causing the infection and determine which antibiotic is most effective against it. Broad spectrum antibiotics are effective against a wide range of bacteria, but they may also kill beneficial bacteria and increase the risk of resistance or superinfection.
Choice C reason: Obtaining a complete blood count and serum electrolytes is not necessary before administering the first dose of a broad spectrum antibiotic, as these tests do not provide information about the type or severity of infection. A complete blood count may show an elevated white blood cell count or other changes in response to infection, but it does not identify the causative organism. Serum electrolytes may show abnormalities due to dehydration, vomiting, diarrhea, or other factors, but they do not indicate infection.
Choice D reason: Performing irrigation and topical antibiotic application to wound area is not sufficient before administering the first dose of a broad spectrum antibiotic, as this may not reach all sites of infection or eradicate all bacteria. Irrigation and topical antibiotic application may help clean and prevent further contamination of wound area, but they do not replace systemic antibiotic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
The correct answer is 200 mL/hr.
Explanation: To calculate the infusion rate, the nurse should use the formula:
Infusion rate (mL/hr) = Volume (mL) / Time (hr)
In this case, the volume is 200 mL and the time is 1 hour. Therefore,
Infusion rate (mL/hr) = 200 mL / 1 hr
Infusion rate (mL/hr) = 200 mL/hr
Correct Answer is D
Explanation
Choice A reason: Assessing for orthostatic hypotension before administering the dose is not necessary, as labetalol does not cause orthostatic hypotension. Orthostatic hypotension is a condition where the blood pressure drops significantly when changing positions from lying to sitting or standing. Labetalol is a beta-blocker that lowers blood pressure by reducing the heart rate and cardiac output.
Choice B reason: Administering the dose and monitoring the client's B/P regularly is not appropriate, as labetalol may cause further bradycardia (slow heart rate) in this client. The client's heart rate is already below normal (48 beats/minute), which may indicate that labetalol is overdosed or contraindicated. Bradycardia can lead to decreased perfusion, dizziness, fatigue, and fainting.
Choice C reason: Applying a telemetry monitor before administering the dose is not sufficient, as labetalol may cause serious cardiac arrhythmias (irregular heart rhythms) in this client. The client's heart rate is already below normal (48 beats/minute), which may indicate that labetalol is affecting the electrical conduction system of the heart. Arrhythmias can cause palpitations, chest pain, shortness of breath, and cardiac arrest.
Choice D reason: Withholding the scheduled dose and notifying the healthcare provider is the best action for the nurse to take in this situation. The client's heart rate is already below normal (48 beats/minute), which may indicate that labetalol is causing adverse effects or interactions with other medications. The healthcare provider should be informed of the client's vital signs and medication history, and decide whether to adjust or discontinue labetalol.
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