The health care provider prescribes IV vancomycin for a patient with pneumonia. Which priority action should the nurse perform before the first dose of the antibiotic?
Check the patient's temperature
Obtain sputum cultures
Check the patient's blood pressure
Draw a blood specimen to evaluate the white blood cell count
The Correct Answer is B
Choice A reason: Checking the patient's temperature is important for assessing the severity of the pneumonia and monitoring for fever, but it is not the priority action before administering the first dose of vancomycin.
Choice B reason: Obtaining sputum cultures is the priority action because it allows for the identification of the causative organism and determination of its antibiotic susceptibility. This helps ensure that the prescribed antibiotic is appropriate for the patient's infection. Cultures should be obtained before starting antibiotic therapy to avoid interference with culture results.
Choice C reason: Checking the patient's blood pressure is important for overall patient assessment and monitoring, especially considering potential side effects of vancomycin. However, it is not the primary action needed before the first dose of the antibiotic.
Choice D reason: Drawing a blood specimen to evaluate the white blood cell count is useful for assessing the severity of the infection and the patient's immune response. However, this can be done after obtaining the sputum cultures and is not the immediate priority before administering the antibiotic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Fluid restrictions are not appropriate for stabilizing a patient with acute anemia. In fact, patients with anemia might require fluid resuscitation to maintain adequate blood volume and pressure. Restricting fluids could potentially worsen the patient's condition.
Choice B reason: Iron supplements are necessary for patients with acute anemia, especially if the anemia is due to iron deficiency. Supplementation helps replenish iron stores in the body, aiding in the production of hemoglobin and red blood cells which are critical for carrying oxygen to tissues.
Choice C reason: PRBC (Packed Red Blood Cells) transfusion is a common and effective intervention for acute anemia. It quickly increases the number of red blood cells in the patient's circulation, thereby improving oxygen delivery to tissues and alleviating symptoms of anemia such as fatigue and weakness.
Choice D reason: O2 therapy, or oxygen therapy, is crucial for stabilizing patients with acute anemia. Anemia results in reduced oxygen-carrying capacity of the blood, and supplemental oxygen helps ensure that tissues receive sufficient oxygen. This intervention can be lifesaving in severe cases of anemia.
Correct Answer is ["A","C"]
Explanation
Choice A reason: Offering high-calorie protein snacks between meals and at bedtime is appropriate for a patient with COPD who is losing weight and eating very little. These snacks can help meet their nutritional needs and provide the extra calories and protein necessary to prevent muscle wasting and support overall health.
Choice B reason: While increasing the intake of whole grains and vegetables is generally healthy, it may not be the priority for a patient who has lost significant weight and needs to focus on higher-calorie, nutrient-dense foods. The primary goal is to address the calorie and protein deficit first.
Choice C reason: Encouraging rest before meals is beneficial as it helps conserve energy for eating. Patients with COPD often experience fatigue, which can reduce their appetite and ability to eat. Resting before meals can help them feel more energetic and better able to consume their meals.
Choice D reason: Providing a large glass of juice with each meal is not ideal for increasing calorie and protein intake. While juice can provide some calories and nutrients, it is not a good source of protein. Additionally, large volumes of liquid can create a feeling of fullness, reducing the patient's appetite for nutrient-dense foods.
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