Nokea
The nurse is preparing to administer IV cefazolin to a newly admitted client with cellulitis. The nurse notes the client is allergic to amoxicillin. Which of the following actions should the nurse take next?
- A. Administer the medication as prescribed.
- B. Administer diphenhydramine before administering cefazolin.
- C. Notify the pharmacy that the medication is not appropriate for the client.
- D. Ask the client for more information about the allergic reaction to amoxicillin.
Correct Answer: D
Rationale: Clients with an allergy to penicillin antibiotics (eg, amoxicillin) can experience a cross-sensitivity reaction
to cephalosporin antibiotics (eg, cefazolin) because the medication molecules are structurally similar. The
nurse should first obtain more information by asking about the type of reaction the client experienced because
allergic reactions can range from mild to severe (Option 4)
Cephalosporins can be safely administered to clients with a history of mild allergic reaction to penicillin (eg,
rash) but are contraindicated for clients with a history of anaphylaxis.
You may also like to solve these questions
The nurse is providing dietary teaching for an elderly client living on fixed income. Which food choices would provide the client with needed nutrients and be cost effective?
- A. Potatoes, green beans, bacon
- B. Spinach, dried beans, tomatoes
- C. Ham, corn, strawberries
- D. Beef, cheese, milk
Correct Answer: B
Rationale: Spinach, dried beans, and tomatoes are nutrient-rich (vitamins, protein, fiber) and cost-effective. Bacon , ham , and beef/cheese/milk are more expensive and less balanced.
A young adult is admitted with a possible head injury. The car in which he was riding hit a utility pole, and the client's head hit the windshield. Baseline vital signs are BP=112/74, P=80, and R=12. The nurse checks the client an hour after admission. Which finding(s) are significant and should be reported to the charge nurse or physician immediately? Select all that apply.
- A. BP=126/68
- B. Pulse=62
- C. Respirations=8
- D. Projectile vomiting
- E. Client's skin is cool to the touch.
- F. Both pupils respond to exposure to flashlight by constricting.
Correct Answer: C,D
Rationale: Slow respirations (8) and projectile vomiting suggest increased intracranial pressure, critical in head injury, requiring immediate reporting. BP, pulse, skin, and pupil response changes are less urgent.
The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time?
- A. Call emergency medical services and place ice packs on the client’s axilla and groin
- B. Encourage the client to leave the venue to visit a health care provider
- C. Evaluate whether the client may be intoxicated
- D. Move the client to an air-conditioned booth and provide a cool sports drink
Correct Answer: D
Rationale: Symptoms suggest heat exhaustion. Moving to a cool area and providing fluids (D) is the first step. EMS (A) is premature, leaving (B) delays care, and intoxication (C) is not indicated.
The nurse observes a client using a walker. Which observation indicates that the client needs more instruction?
- A. The client uses the walker to pull herself out of a chair.
- B. The client moves the walker forward and then takes a step.
- C. The client complains that the walker is not waist high.
- D. The client sometimes does not use the walker.
Correct Answer: A
Rationale: Using the walker to pull up risks tipping, indicating improper use and a need for further instruction on safe walker technique.
The nurse is caring for a client with panic disorder who is reporting palpitations and intense feelings of fear. The client is shaking and hyperventilating. Which of the following actions would be a priority for the nurse to take?
- A. Assess the client for auditory and visual hallucinations.
- B. Administer a benzodiazepine to the client.
- C. Explore possible triggers for the episode with the client
- D. Remain in the room with the client.
Correct Answer: D
Rationale: Staying with the client (D) provides safety and reassurance, reducing fear and hyperventilation during a panic attack. Hallucinations (A) are not typical, medication (B) is secondary, and exploring triggers (C) is appropriate after stabilization.