The nurse receives an order to administer cefazolin to a client diagnosed with a urinary tract infection. The nurse withholds the medication and notifies the health care provider because the client:
Has not received proper education on this medication.
Just completed a full course of an aminoglycoside antibiotic.
Is currently afebrile.
Had a prior anaphylactic reaction to penicillin.
The Correct Answer is D
Choice A rationale
While it’s important for clients to understand their medications, not having received proper education on this medication is not a reason to withhold cefazolin.
Choice B rationale
Completing a full course of an aminoglycoside antibiotic does not contraindicate the use of cefazolin.
Choice C rationale
Being afebrile does not contraindicate the use of cefazolin. Antibiotics are used to treat bacterial infections, not just to reduce fever.
Choice D rationale
A prior anaphylactic reaction to penicillin is a contraindication for administering cefazolin. Cefazolin is a cephalosporin, and there is a risk of cross-reactivity and potential allergic reaction in clients who have a history of severe penicillin allergy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Reddish feet when put down could be a sign of dependent rubor, a condition that occurs due to peripheral arterial disease (PAD). When the legs are in a dependent (downward) position, gravity aids in delivering blood to the area, causing a reddish color. However, this is a common symptom of PAD and does not require immediate intervention.
Choice B rationale
Loss of hair on the feet and legs is another symptom of PAD1. This happens because inadequate blood flow deprives the hair follicles of the nutrients they need to grow. While this symptom indicates worsening PAD, it does not warrant immediate intervention.
Choice C rationale
Applying a heating pad to cold legs could lead to burns because PAD can cause loss of sensation in the legs. This warrants immediate intervention to prevent injury.
Choice D rationale
Leg pain during walking, also known as claudication, is a common symptom of PAD1. This happens because the muscles are not getting enough oxygen due to reduced blood flow.
However, this symptom does not require immediate intervention but should be evaluated further.
Correct Answer is D
Explanation
Choice D rationale
The symptoms described - edema, severe pain, paresthesia, and tightness of the operative limb
- are indicative of Compartment Syndrome. This is a serious condition that can occur after surgery, where increased pressure within one of the body’s compartments results in insufficient blood supply to the area. It requires immediate treatment to prevent permanent damage.
Choice A rationale
While wound infection is a possible post-operative complication, it would typically present with symptoms such as redness, increased pain at the wound site, purulent discharge, and possibly fever. The symptoms described do not specifically indicate a wound infection.
Choice B rationale
Internal bleeding could cause pain and swelling, but it would likely also present with signs of shock, such as low blood pressure, increased heart rate, and altered mental status. The symptoms provided do not clearly indicate internal bleeding.
Choice C rationale
Graft rupture is a serious complication that could potentially cause severe pain and swelling. However, it would also likely cause significant hemodynamic instability, including hypotension and tachycardia. The symptoms described are more indicative of Compartment Syndrome.
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