Nokea
A nurse is preparing to administer a prescribed cephalosporin by injection. Which of the following would be most important for the nurse to keep in mind? Select all that apply.
- A. Thrombophlebitis can occur when cephalosporins are given IV.
- B. Phlebitis can occur when cephalosporins are given IM.
- C. Pain can occur when cephalosporins are given IM.
- D. Tenderness can occur when cephalosporins are given IM.
- E. Swelling can occur when cephalosporins are given IM.
Correct Answer: A,C,D,E
Rationale: Administration route reactions include pain, tenderness, and inflammation at the injection site when cephalosporins are given IM, and phlebitis and thrombophlebitis along the vein may occur when cephalosporins are given IV.
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A nurse suspects that a client receiving oral penicillin therapy is developing pseudomembranous colitis based on assessment of which of the following?
- A. Bloody diarrhea
- B. Pruritus
- C. Chills
- D. Hives
Correct Answer: A
Rationale: Pseudomembranous colitis is a severe, life-threatening form of diarrhea that occurs when normal flora of the bowel is eliminated and replaced with C. difficile bacteria. It is manifested by bloody diarrhea. Pruritus and hives would suggest an allergic reaction. Chills could indicate a wide range of problems.
A patient undergoing penicillin therapy shows improvement and states that he is feeling better. Which of the following interventions is the nurse most likely to perform in such a situation?
- A. Instruct patient to increase dietary intake.
- B. Inform the primary health provider immediately.
- C. Record assessments on patient's chart.
- D. Inquire about any previous drug allergies.
Correct Answer: C
Rationale: When the patient declares that he is feeling better and is also showing improved health, it should be recorded on the patient's chart. If the condition of the patient has improved, the patient will show an increased appetite, but there is no need to instruct the patient to increase dietary intake. The primary health provider need not be informed about the condition immediately unless the patient shows signs of deterioration or complications. The nurse should inquire about previous drug allergies before the start of therapy.
A nurse is caring for a patient who is receiving penicillin. The nurse would assess for which of the following as a common adverse reaction?
- A. Inflammation of the tongue and mouth
- B. Impaired oral mucous membranes
- C. Severe hypotension
- D. Sudden loss of consciousness
Correct Answer: A
Rationale: Some of the common adverse effects of penicillin are glossitis (inflammation of the tongue), stomatitis (inflammation of the mouth), and gastritis (inflammation of the stomach). Unless the adverse effects are severe, the drug may be continued as prescribed and the nurse would intervene to help the patient manage the common adverse reactions. Impaired oral mucous membranes would suggest a possible fungal superinfection in the oral cavity, whereas severe hypotension and sudden loss of consciousness are signs of anaphylactic shock; these are not common adverse effects of penicillin and require immediate medical attention.
Before administering the first dose to the client, which assessment should the nurse perform as part of the preadministration assessment?
- A. Review of renal and hepatic function tests
- B. Inspection of patient's stools
- C. Evaluation of patient's lifestyle and diet
- D. General history of patient's health
Correct Answer: D
Rationale: Before administering the first dose of penicillin, the nurse should obtain and review the patient's general health history, including any allergy history, a history of all medical and surgical treatments, a drug history, and the current symptoms of the infection. The patient's stool is examined only after penicillin has been administered if the patient has diarrhea. It is not required to evaluate the patient's lifestyle and diet as part of the preadministration assessment for the first dose. Renal and hepatic function tests may be performed at intervals during penicillin therapy, usually not before it.
A nurse is teaching a patient about the common adverse reactions that can occur with his prescribed therapy with cephalosporins. The nurse determines that the teaching was successful when the patient identifies which of the following? Select all that apply.
- A. Drowsiness
- B. Headache
- C. Constipation
- D. Heartburn
- E. Vomiting
Correct Answer: B,D,E
Rationale: Common adverse reactions to cephalosporins include nausea, vomiting, diarrhea, headache, dizziness, malaise, heartburn, and fever.