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 ["B"]

Explanation

Choice A reason: Cleaning the stoma two times a week is not sufficient. Stoma care typically requires daily cleaning to prevent infection and ensure the area remains free from mucus buildup and irritation.

Choice B reason: Using a bedside humidifier is important for patients with a tracheostomy. The humidified air helps to keep the stoma and airway moist, preventing drying and crusting of secretions, which can obstruct the airway.

Choice C reason: Offering plenty of fluids to the patient helps to keep the mucus thin and easier to clear, which is crucial for maintaining a clear airway in patients with a tracheostomy.

Choice D reason: Keeping the stoma uncovered when the patient showers is incorrect. The stoma should be covered with a waterproof shield or dressing to prevent water from entering the airway, which can cause respiratory distress or infection.

A. Ask the patient about loose stools B. Suggest that the healthcare provider order a basic metabolic panel C. Assess for facial muscle spasms D. Call for a rapid response team

Correct Answer is B

Explanation

Choice A reason: Asking the patient about loose stools is important as it can help identify possible causes of fluid and electrolyte imbalances. However, this question alone would not be the immediate or primary action to take in response to generalized weakness.

Choice B reason: Suggesting that the healthcare provider order a basic metabolic panel is the most appropriate action. Potassium-wasting diuretics can lead to hypokalemia, which can cause symptoms like generalized weakness. A basic metabolic panel will provide information on the patient's electrolyte levels, including potassium, and help determine if the weakness is due to an electrolyte imbalance. This allows for appropriate intervention to correct the imbalance and prevent further complications.

Choice C reason: Assessing for facial muscle spasms is relevant because hypokalemia can cause muscle cramps and spasms. However, it does not address the root cause of the weakness and does not lead to immediate intervention.

Choice D reason: Calling for a rapid response team is generally reserved for situations where the patient is experiencing acute, life-threatening symptoms requiring immediate intervention. Generalized weakness in the context of a patient on a potassium-wasting diuretic does not usually necessitate such an urgent response unless it progresses to more severe symptoms.

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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

Which action would the nurse take while providing home care to a patient with a stoma after a tracheostomy? Select all that apply. One, some, or all responses may be correct.

Correct Answer is ["B"]

Explanation

A patient who is taking a potassium-wasting diuretic for the treatment of hypertension reports generalized weakness. Which action is appropriate for the nurse to take?

Correct Answer is B

Explanation

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