The nurse is preparing to administer an aminoglycoside antibiotic to a client admitted with a diagnosis of acute diverticulitis.
What is the priority nursing action?

Monitor the peak level of the antibiotic.

Assess the client’s vital signs.

Obtain a serum trough level.

Ask the client about drug allergies.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Monitoring the peak level of the antibiotic is important, but it is not the priority nursing action. Peak levels are typically drawn after the drug has been administered and are used to assess whether the dosage is sufficient.

Choice B rationale

Assessing the client’s vital signs is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.

Choice C rationale

Obtaining a serum trough level is the priority nursing action. Trough levels are drawn just before the next dose of the drug is due and are used to assess whether the dosage is safe.

Choice D rationale

Asking the client about drug allergies is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.

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Correct Answer is D

Explanation

Choice A rationale

While obtaining a full set of vital signs is an important part of assessing a patient’s condition, it should not be the initial action in this case. The symptoms described by the patient suggest hypoglycemia, which requires immediate confirmation and treatment.

Choice B rationale

Administering 1 mg glucagon subcutaneously is not the initial action. Glucagon is used to treat severe hypoglycemia when the patient is unable to take glucose orally. However, the patient’s blood glucose level should be checked first.

Choice C rationale

Administering 25 mL of 50% dextrose is not the initial action. This treatment is used for severe hypoglycemia, but the patient’s blood glucose level should be checked first to confirm hypoglycemia.

Choice D rationale

Obtaining a blood glucose reading is the correct initial action. The symptoms described by the patient suggest hypoglycemia. Checking the blood glucose level will confirm whether the patient is hypoglycemic and needs treatment.

A. Increase intake of proteins, take vitamin C and zinc B. Use care when walking to avoid bumping your limb C. Cleanse the ulcer with soap and water D. Apply cortisone cream to decrease itching E. Put on compression stockings before getting out of bed

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale

Proteins, vitamin C, and zinc are essential for wound healing. Proteins are the building blocks for body tissue, and zinc plays a role in protein synthesis. Vitamin C is needed for the formation of collagen, a protein used to make skin, scar tissue, and blood vessels.

Choice B rationale

Care should be taken when walking to avoid bumping the limb. Any trauma to the affected limb could potentially worsen the condition or delay healing.

Choice C rationale

Cleaning the ulcer with soap and water may not be the best option. Soap can be irritating to the skin and may delay healing. Instead, the ulcer should be cleaned as per healthcare provider’s instructions.

Choice D rationale

Cortisone cream is not typically used for venous stasis ulcers. It can thin the skin and delay healing.

Choice E rationale

Compression stockings are often recommended for patients with post-thrombotic syndrome. They can help reduce swelling and improve blood flow, which can promote healing of the venous stasis ulcer.

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The nurse is preparing to administer an aminoglycoside antibiotic to a client admitted with a diagnosis of acute diverticulitis. What is the priority nursing action?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is recovering from an episode of diabetic ketoacidosis and reports feeling “anxious, shaky, and sweaty.”. What should be the nurse’s initial action?

Correct Answer is D

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is providing care for a client diagnosed with post-thrombotic syndrome who has a venous stasis ulcer. Which instructions should be given prior to discharge? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Choice E rationale

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The nurse is preparing to administer an aminoglycoside antibiotic to a client admitted with a diagnosis of acute diverticulitis.
What is the priority nursing action?