Nokea
A nurse is preparing to administer a new prescription for ampicillin 1.5g IV every 6 hr to a client who has an upper respiratory infection. The client also has a prescription for a sputum specimen for culture and sensitivity. Which of the following actions should the nurse plan to take?
- A. Verify the prescription.
- B. Administer the medication at 1000, 1400, 1800, and 2200.
- C. Assess the client for an allergy to penicillin
- D. Document giving the medications
- E. Obtain a sputum for culture and sensitivity
Correct Answer: A,C,D,E
Rationale: Correct Answer: A, C, D, E
Rationale:
A: Verify the prescription - It is essential for the nurse to confirm the accuracy and appropriateness of the new medication order before administration.
C: Assess the client for an allergy to penicillin - Since ampicillin is a penicillin antibiotic, it is crucial to evaluate the client for any potential allergic reactions.
D: Document giving the medications - Documentation is a critical aspect of nursing practice to ensure accurate recording of the medication administration.
E: Obtain a sputum for culture and sensitivity - This action is necessary to identify the causative organism and determine the most effective antibiotic therapy for the client's infection.
Summary:
B: Administering the medication at specific times is not relevant to the question.
F, G: No additional options provided.
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A nurse is preparing to administer ampicillin/sulbactam 15 g via intermittent IV bolus, Available is ampicillin-sulbactam 1.5 g in 0.9% sodium chloride 100 mL to infuse over 30 min. The nurse should set the IV infusion pump to deliver how many mL/h?
- A. 200 mL/h
Correct Answer: A
Rationale: The correct answer is A: 200 mL/h. To calculate the infusion rate, you first need to convert the total dose of ampicillin/sulbactam to mL. The concentration is 1.5 g in 100 mL, so 15 g would be in 1000 mL. The infusion time is 30 min, so you need to convert it to hours (30 min ÷ 60 = 0.5 hours). Next, divide the total volume (1000 mL) by the infusion time (0.5 hours) to get 2000 mL/h. Therefore, the nurse should set the IV pump to deliver 200 mL/h. Other choices are incorrect as they do not follow the correct calculations based on the given information.
A nurse is providing teaching for a client who has a prescription for gentamicin. Which of the following should the nurse include as an adverse effect of this medication?
- A. Urinary frequency
- B. Constipation
- C. Hypertension
- D. Tinnitus
Correct Answer: D
Rationale: The correct answer is D: Tinnitus. Gentamicin is known to cause ototoxicity, including tinnitus, which is a ringing or buzzing sound in the ears. This adverse effect is important for the nurse to include in teaching to monitor for hearing changes. Urinary frequency (A), constipation (B), and hypertension (C) are not commonly associated with gentamicin use, so they are incorrect choices.
A nurse is caring for a client who is receiving meperidine. Which of the following is the nurse's priority assessment before administering the medication?
- A. Urinary retention
- B. Vomiting
- C. Respiratory rate
- D. Level of consciousness
Correct Answer: C
Rationale: The correct answer is C: Respiratory rate. Meperidine is an opioid analgesic that can cause respiratory depression. Therefore, assessing the client's respiratory rate before administering the medication is crucial to prevent potential respiratory compromise. This assessment helps the nurse ensure the client can safely tolerate the medication and intervene promptly if respiratory depression occurs.
Urinary retention (choice A) is a potential side effect of meperidine but is not the priority assessment compared to respiratory rate. Vomiting (choice B) may be a concern in terms of medication absorption but does not directly relate to the risk of respiratory depression. Level of consciousness (choice D) is important but may be influenced by respiratory status, making respiratory rate the priority assessment.
A nurse is providing teaching to a client who has a new prescription for atenolol. Which of the following adverse effects should the nurse include in the teaching?
- A. Lightheadedness
- B. Tachycardia
- C. Dry mouth
- D. Bronchodilation
Correct Answer: A
Rationale: The correct answer is A: Lightheadedness. Atenolol is a beta-blocker that can cause a decrease in blood pressure, leading to lightheadedness due to reduced blood flow to the brain. Tachycardia (choice B) is not an adverse effect as atenolol actually slows down the heart rate. Dry mouth (choice C) is not a common adverse effect of atenolol. Bronchodilation (choice D) is not expected with atenolol as it can actually cause bronchoconstriction in some individuals.
A nurse is providing discharge teaching to a client who has a prescription for enoxaparin. Which of the following instructions should the nurse include in the teaching?
- A. Insert the needle at a 45 angle
- B. Inject the medication into a muscle
- C. Rub the injection site following administration
- D. Expel the air bubble prior to injecting the medication
Correct Answer: D
Rationale: The correct answer is D: Expel the air bubble prior to injecting the medication. This is crucial to prevent air embolism. Step 1: Remove the cap and air bubbles from the syringe. Step 2: Push the plunger to remove air from the syringe until a small drop of medication appears at the needle tip. Step 3: Inject the medication subcutaneously at a 90-degree angle. Step 4: Dispose of the needle properly. Choice A is incorrect as enoxaparin is administered subcutaneously. Choice B is incorrect as it should not be injected into a muscle. Choice C is incorrect as rubbing the injection site can cause irritation.