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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice C reason: Sodium polystyrene sulfonate is a cation-exchange resin that binds to potassium in the intestine and removes it from the body through the stool. Sodium polystyrene sulfonate is used to treat hyperkalemia, or high potassium level, which can be caused by AKI, certain medications, or other conditions. Hyperkalemia can cause cardiac arrhythmias, muscle weakness, paralysis, or death. The normal range of potassium for adults is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore, a decrease in potassium from above normal to within normal indicates that sodium polystyrene sulfonate has been effective in lowering potassium level and preventing complications. The nurse should monitor the client's serum potassium level regularly and adjust the dose of sodium polystyrene sulfonate as needed.

Choice A reason: Hemoglobin level of 13.5 g/dL (135 g/L) is not a laboratory finding that indicates that the medication has been effective, but rather a normal value that reflects the amount of oxygen-carrying protein in the blood. Hemoglobin is not affected by sodium polystyrene sulfonate or potassium level. The normal range of hemoglobin for adults is 12 to 16 g/dL (120 to 160 g/L). Therefore, a hemoglobin level of 13.5 g/dL does not indicate any change or improvement in the client's condition.

Choice B reason: Serum glucose level of 120 mg/dL (6.7 mmol/L) is not a laboratory finding that indicates that the medication has been effective, but rather a slightly elevated value that reflects the amount of sugar in the blood. Glucose is not affected by sodium polystyrene sulfonate or potassium level. The normal range of glucose for adults is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Therefore, a serum glucose level of 120 mg/dL may indicate impaired glucose metabolism or diabetes mellitus, but not the effectiveness of sodium polystyrene sulfonate.

Choice D reason: Serum ammonia level of 30 mg/dL (17.62 µmol/L) is not a laboratory finding that indicates that the medication has been effective, but rather a normal value that reflects the amount of nitrogen waste in the blood. Ammonia is not affected by sodium polystyrene sulfonate or potassium level. The normal range of ammonia for adults is 10 to 80 mg/dL (6 to 47 µmol/L). Therefore, a serum ammonia level of 30 mg/dL does not indicate any change or improvement in the client's condition.

A. Check the client's capillary glucose level. B. Advise the client to reduce the medication dose. C. Report the finding to the healthcare provider. D. Use a pulse oximeter to assess oxygen saturation.

Correct Answer is C

Explanation

Choice A reason: Checking the client's capillary glucose level is not relevant to this finding, as acetaminophen does not affect blood glucose levels. The yellow color of the skin may indicate jaundice, which is a sign of liver damage caused by acetaminophen overdose or toxicity.

Choice B reason: Advising the client to reduce the medication dose is not sufficient to address this finding, as acetaminophen can cause irreversible liver damage if taken in excess or for prolonged periods. The client may need immediate medical attention and treatment with an antidote such as N-acetylcysteine.

Choice C reason: Reporting the finding to the healthcare provider is the appropriate action to take, as the yellow color of the skin may indicate jaundice, which is a sign of liver failure caused by acetaminophen overdose or toxicity. The healthcare provider can order further tests and interventions to assess and treat the client's condition.

Choice D reason: Using a pulse oximeter to assess oxygen saturation is not related to this finding, as acetaminophen does not affect oxygen levels. The yellow color of the skin may indicate jaundice, which is a sign of liver dysfunction caused by acetaminophen overdose or toxicity.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

Correct Answer is C

Explanation

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