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 A

Explanation

Choice A reason: Hypertension, often called the "silent killer," is usually asymptomatic until significant target organ damage has occurred. This means that many people with hypertension do not experience symptoms until their blood pressure has been high for a long time, leading to damage in organs such as the heart, kidneys, brain, and eyes. Therefore, it's crucial for patients to understand the importance of regular blood pressure monitoring and management even in the absence of symptoms.

Choice B reason: While annual BP checks are useful for monitoring treatment effectiveness, more frequent monitoring may be necessary for newly diagnosed patients or those with poorly controlled hypertension. This information is important but not the most critical point compared to understanding the asymptomatic nature of hypertension.

Choice C reason: Increasing physical activity can help control blood pressure for many individuals, but it is not universally effective for everyone. While important, this information is part of a broader lifestyle modification plan rather than the single most critical point to emphasize.

Choice D reason: Dietary changes can play a significant role in controlling blood pressure, but not all individuals can control their BP through diet alone. Emphasizing this may give a false sense of control without highlighting the importance of medication and other interventions when needed.

A. Hypotension, chills, thirst B. Lethargy, confusion, bradycardia C. Bradycardia, hypotension, low urine output D. Fever, tachycardia, tremors

Correct Answer is D

Explanation

Choice A reason: Hypotension, chills, and thirst are not characteristic signs and symptoms of a thyroid storm. Hypotension generally indicates low blood pressure, while chills and thirst are less specific symptoms that do not particularly point to thyroid storm.

Choice B reason: Lethargy, confusion, and bradycardia are not typical indicators of a thyroid storm. These symptoms might be present in other conditions but are not generally associated with the severe hypermetabolic state seen in thyroid storms.

Choice C reason: Bradycardia, hypotension, and low urine output are also not typical signs of a thyroid storm. Bradycardia (slow heart rate) and hypotension (low blood pressure) are more likely associated with severe hypothyroidism or other conditions, not the hyperactive state of a thyroid storm.

Choice D reason: Fever, tachycardia, and tremors are classic signs of a thyroid storm. A thyroid storm is a life-threatening condition characterized by an excessive amount of thyroid hormones, leading to hypermetabolic activity. This results in symptoms like a high fever, rapid heart rate (tachycardia), and tremors.

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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

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