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.
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The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply.
- A. Do not leave a tourniquet on more than 1 minute while looking for a vein
- B. Draw the specimen while the skin is still wet with the alcohol prep
- C. If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes
- D. Use a highly visible vein on the ventral side of the client's wrist
- E. Vigorously shake the specimen tube to mix obtained blood with anticoagulant solution
Correct Answer: A,C
Rationale: A tourniquet left on too long (A) can cause hemoconcentration, so it should be removed after 1 minute. Pulsating blood (C) indicates arterial puncture, requiring immediate needle withdrawal and pressure to prevent hematoma. Wet alcohol (B) can cause hemolysis, and the ventral wrist (D) is a risky site due to nerves and arteries. Vigorous shaking (E) damages blood cells, so gentle inversion is preferred.
A client with gout who was started on allopurinol a week ago calls the health care provider’s office with several concerns. The nurse should recognize which report by the client as being significant and requiring immediate follow-up?
- A. Also takes ibuprofen for pain
- B. Frequency of urination has increased
- C. Mild red rash has developed over torso
- D. Nausea occurs after each dose
Correct Answer: C
Rationale: A rash (C) may indicate a hypersensitivity reaction to allopurinol, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate follow-up. Ibuprofen (A), urination (B), and nausea (D) are less urgent.
The male client had a hemicolectomy. The client is refusing to wear the prescribed sequential compression devices (SCDs). What is most important for the nurse to communicate to the client?
- A. An appropriate form must be signed, verifying refusal
- B. Complications, including death, could result
- C. The client will be billed for the equipment regardless
- D. The surgeon will be informed of the refusal
Correct Answer: B
Rationale: SCDs prevent deep vein thrombosis (DVT) post-surgery, a potentially fatal complication. Communicating the risk of complications, including death (B), is critical to emphasize the importance of compliance. Signing a refusal form (A), billing (C), or informing the surgeon (D) are secondary to ensuring the client understands the serious risks.
The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
- A. Decreased breath sounds in right lower lobe
- B. Aspiration of a residual of 100 cc of formula
Correct Answer: A
Rationale: Decreased breath sounds in the right lower lobe may indicate aspiration or pneumonia, a serious complication requiring immediate intervention to ensure airway patency and prevent further respiratory compromise.
During the evaluation phase for a client, the nurse should focus on
- A. All finding of physical and psychosocial stressors of the client and in the family
- B. The client's status, progress toward goal achievement, and ongoing re-evaluation
- C. Setting short and long-term goals to insure continuity of care from hospital to home
- D. Select interventions that are measurable and achievable within selected timeframes
Correct Answer: B
Rationale: The client's status, progress toward goal achievement, and ongoing re-evaluation. Evaluation focuses on assessing progress and adjusting the care plan.