The nurse continues caring for the client.
Complete the following sentence by using the lists of options.
The nurse should
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Rationale for correct choice:
- Clarify the antibiotic prescription with the provider: The client has a known penicillin allergy, and ceftriaxone is a cephalosporin, which may cross-react with penicillin. The nurse should clarify this prescription to prevent a potential allergic reaction.
- Penicillin allergy: Due to the client's penicillin allergy, it’s essential to ensure that no antibiotics containing penicillin or related compounds are administered. Ceftriaxone should be verified with the provider to avoid causing an allergic reaction.
Rationale for incorrect choices:
- Perform medication reconciliation: While important, medication reconciliation is not as urgent as clarifying the antibiotic prescription to avoid a potential allergic reaction to ceftriaxone.
- Request a prescription for doxycycline: Doxycycline is not needed in this situation, as the prescribed antibiotics are appropriate for treating common STIs following sexual assault. The client is also allergic to doxycycline.
- Potential HIV exposure: HIV post-exposure prophylaxis (PEP) should be considered, but the priority here is to clarify the antibiotics. PEP can be addressed later with informed consent and appropriate protocols.
- Need for prophylaxis for human papillomavirus (HPV): HPV prophylaxis is not part of standard post-sexual assault care. Focus should be on preventing STIs, pregnancy, and HIV rather than HPV at this stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Complete the following sentence by using the lists of options.
The client is at risk of developing
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
Rationale for correct choices:
- Alcohol withdrawal syndrome: The client’s BAC of 310 mg/dL indicates severe intoxication. As the alcohol clears from the system, withdrawal symptoms such as anxiety, tremors, and seizures may occur, requiring close monitoring to prevent complications like delirium tremens.
- Blood alcohol level of 310 mg/dL: This elevated BAC indicates significant alcohol consumption. As the alcohol is metabolized, the client is at high risk for alcohol withdrawal syndrome and requires close observation to manage withdrawal symptoms as the BAC decreases.
Rationale for incorrect choices:
- Malnutrition: While weight loss and minimal appetite may be concerning, they do not definitively indicate malnutrition. These symptoms are more likely tied to the client’s psychological distress and alcohol use rather than severe nutritional deficiency.
- Alcohol intoxication: The client’s current state is intoxicated; the primary concern at this stage is managing alcohol withdrawal syndrome. Once the alcohol is metabolized, the focus will shift to preventing withdrawal complications which the client is at risk of.
- Respiratory rate of 10/min: A respiratory rate of 10/min is on the low side but not dangerously low. This rate may be associated with alcohol intoxication and will require monitoring but is not immediately alarming unless the client shows signs of respiratory distress.
- Weight loss over the past 3 months and minimal appetite: The weight loss and reduced appetite are concerning but not immediately indicative of malnutrition. These symptoms are likely due to the client’s alcohol use and emotional distress, and further assessment is needed to evaluate nutritional health.
Correct Answer is A
Explanation
A. Transfer a client who has delirium from a bed to a wheelchair: Assisting with transfers and mobility is within the scope of practice for an AP, especially if the client is stable and the task does not require clinical decision-making.
B. Inform a client who has schizophrenia about available community services: This task requires clinical judgment and communication skills to ensure that the client understands the information and that the services are appropriate for their needs. It should be performed by a nurse, not an AP.
C. Obtain a list of current medications from a client who is experiencing a manic episode: While obtaining a medication list is an important task, it requires assessment and evaluation of the client's condition, which should be done by a nurse, especially when the client is in a manic state and may have impaired judgment or communication.
D. Insert an NG tube for a client who has acetaminophen toxicity: Inserting an NG tube is an invasive procedure that requires clinical knowledge and skill. It should be performed by a licensed nurse or physician, not an AP.