Nokea
Medication Administration Record
Ceftriaxone 2 gm IV BID
Acetaminophen 325 mg PO every 4 hr PRN fever over 39° C (102.2° F)
Guaifenesin 200 mg PO every 4 hr PRN cough
Diagnostic Results
Complete Blood Count:
Hemoglobin 15 g/dL (12 to 16 g/dL)
Hematocrit 45% (37% to 47%)
WBC count 15,000/mm* (5000 to 10,000/mm*)
Basic Metabolic Profile:
Creatinine 2.8 mg/dL (0.5 to 1.1 mg/di)
BUN 19 mg/dL (10 to 20 mg/dL)
Sputum Culture and Sensitivity:
Klebsiella pneumonia
A nurse is reviewing the medical record of a client who has pneumonia. Which of the following information is the priority for the nurse report to the provider?
- A. Sputum results
- B. Creatinine level
- C. Temperature
- D. WBC count
- E. Oxygen saturation
- F. Blood pressure
- G. Respiratory rate
Correct Answer: B
Rationale: Elevated creatinine (2.8 mg/dL) indicates potential kidney injury, a priority over sputum (expected Klebsiella), WBC (infection), or temperature.
You may also like to solve these questions
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will perform breast exams the day my period begins.
- B. I will perform breast exams every other month.
- C. It is common for the skin on my breasts to dimple.
- D. It is common for one breast to be larger than the other.
Correct Answer: D
Rationale: It's normal for one breast to be slightly larger than the other, and this statement reflects an accurate understanding of breast anatomy. Dimpling can be a sign of concern, and exams should be done monthly, about a week after the period starts, not on the first day or every other month.
A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?
- A. Encourage three large meals daily.
- B. Administer an antiemetic after each meal.
- C. Season foods with spices.
- D. Provide a high-calorie diet.
Correct Answer: D
Rationale: A high-calorie diet addresses malnutrition in AIDS by meeting increased metabolic needs. Large meals may be overwhelming, antiemetics are given before meals if needed, and spices may not be tolerated.
A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?
- A. Administer enemas 2 days before the procedure
- B. Do not eat or drink anything except water for 12 hr. before the procedure.
- C. Restrict the diet to clear liquids for 1 to 3 days before the procedure.
- D. Expect the provider to schedule another procedure to remove any polyps
Correct Answer: B
Rationale: A 12-hour fast with only water prepares the colon adequately for a colonoscopy, reflecting standard protocol and client understanding.
A nurse is reinforcing teaching with a newly licensed nurse who is caring for a client who has AIDS. The nurse should instruct the newly licensed nurse to clean spills of the client's blood with a solution of water and which of the following cleaning agents?
- A. Isopropyl alcohol
- B. Bleach
- C. Hydrogen peroxide
- D. Chlorhexidine
Correct Answer: B
Rationale: A 1:10 bleach solution is the standard for decontaminating blood spills in AIDS care, effectively killing HIV. Other agents are less effective against bloodborne pathogens.
A nurse is obtaining a medication history from a client who is to start taking nitroglycerin for chest discomfort with activity. Which of the following medications should the nurse instruct the client to avoid taking within 24 hr of using nitroglycerin?
- A. Atorvastatin
- B. Sildenafil
- C. Omeprazole
- D. Metformin
- E. Aspirin
- F. Ibuprofen
- G. Warfarin
Correct Answer: B
Rationale: Sildenafil (Viagra) with nitroglycerin can cause severe hypotension; other meds don't interact significantly.