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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Administering antibiotics is essential for treating cellulitis to eliminate the infection. However, it is not the immediate priority over maintaining oxygenation, especially in a patient with sickle cell disease.

Choice B reason: Starting IV fluids is crucial for preventing dehydration and helping to reduce the sickling of red blood cells. Nevertheless, while important, it is not the most urgent action compared to maintaining adequate oxygen levels.

Choice C reason: Assessing pain every 4 hours is necessary for managing the patient's comfort and monitoring the progression of the disease. Although pain management is a significant aspect of care, it is not the top priority in this scenario.

Choice D reason: Maintaining oxygenation is the highest priority for a patient with sickle cell disease. These patients are at increased risk for hypoxia, which can exacerbate the sickling of red blood cells, leading to severe complications such as acute chest syndrome or stroke. Ensuring adequate oxygenation helps to prevent these complications and stabilizes the patient's condition.

A. Perform assisted coughing. B. Administer steroids. C. Administer oxygen. D. Administer antibiotic drugs.

Correct Answer is ["A","C"]

Explanation

Choice A reason: Performing assisted coughing is crucial for patients with spinal cord injuries who may have weakened respiratory muscles. Assisted coughing helps clear secretions from the airways, thus improving oxygenation and preventing respiratory complications like pneumonia.

Choice B reason: Administering steroids is not a primary intervention for addressing hypoxia in patients with spinal cord injuries. Steroids can be used to reduce inflammation, but they do not directly improve respiratory status or oxygenation.

Choice C reason: Administering oxygen is a direct and effective intervention for managing hypoxia. Supplemental oxygen helps ensure that the patient maintains adequate blood oxygen levels, which is critical for overall tissue perfusion and function.

Choice D reason: Administering antibiotics is not immediately relevant to the treatment of hypoxia unless there is an underlying infection causing or contributing to respiratory distress. Antibiotics are used to treat infections, not directly to improve respiratory status in cases of hypoxia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with sickle cell disease has developed cellulitis above the left ankle. Which action is the nurse's priority for this patient?

Correct Answer is D

Explanation

The arterial blood gas (ABG) report of a patient with a spinal cord injury indicates hypoxia. Select two interventions the nurse would perform to improve the patient's respiratory status.

Correct Answer is ["A","C"]

Explanation

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