Nokea
While administering vancomycin IV to a patient, the nurse suspects that the patient is developing redeman syndrome based on assessment of which of the following? Select all that apply.
- A. Headache
- B. Throbbing neck pain
- C. Chills
- D. Erythema of the neck and back
- E. Difficulty breathing
Correct Answer: B,C,D
Rationale: Red-man syndrome is manifested by a decrease in blood pressure, occurrence of throbbing neck or back pain, fever, chills, paresthesias, and erythema of the neck and back. Headache is unrelated to this syndrome. Difficulty breathing might suggest an anaphylactic reaction.
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After teaching a group of nursing students about penicillins, the instructor determines that the teaching was successful when the students identify which of the following as a group? Select all that apply.
- A. Synthetic penicillins
- B. Natural penicillins
- C. Penicillinase-resistant penicillins
- D. Aminopenicillins
- E. Extended-spectrum penicillins
Correct Answer: B,C,D,E
Rationale: Penicillins are categorized into four groups including the natural penicillins, penicillinase-resistant penicillins, aminopenicillins, and extended-spectrum penicillins.
A patient receiving penicillin therapy tells the nurse that she feels like her mouth is irritated and that she has a sore throat. Inspection reveals a red, swollen tongue with ulcerations. The nurse suspects a fungal superinfection and identifies which nursing diagnosis as most appropriate for this patient?
- A. Impaired Comfort
- B. Impaired Oral Mucous Membranes
- C. Deficient Knowledge
- D. Inadequate Nutrition: Less Than Body Requirements
Correct Answer: B
Rationale: The assessment suggests a fungal superinfection, which would lead to the nursing diagnosis of Impaired Oral Mucous Membranes. Although Impaired Comfort may be appropriate, Impaired Oral Mucous Membranes is more specific. There is no evidence of lack of knowledge or problems with nutrition. However, if the superinfection is not addressed, the patient may experience difficulty eating due to the irritation and discomfort.
A nurse is required to administer a parenteral form of penicillin to a patient. Which of the following interventions would be most appropriate for the nurse to do when preparing penicillin in parenteral form?
- A. Extract penicillin from vial and then reconstitute.
- B. Save excess antibiotic after reconstitution for later use.
- C. Use any available diluent for reconstitution.
- D. Shake the vial well to distribute the drug evenly.
Correct Answer: D
Rationale: When preparing a parenteral form of penicillin, the nurse should shake the vial thoroughly before withdrawing the drug to ensure its even distribution in the solution. Penicillins in powder or crystalline form must be reconstituted before being withdrawn from the vial. Excess antibiotic after reconstitution should never be saved, as the drug loses its potency when stored. Reconstitution should be done only with the diluent prescribed on the manufacturer's label.
After teaching a group of students about antibacterial drugs that disrupt the bacterial cell wall, the instructor determines that the teaching was successful when the students identify which of the following as an example of a carbapenem? Select all that apply.
- A. Vancomycin
- B. Imipenem-cilastatin
- C. Meropenem
- D. Aztreonam
- E. Ceftriaxone
Correct Answer: B,C
Rationale: Carbapenems include imipenem-cilastatin and meropenem. Vancomycin and aztreonam are classified as miscellaneous drugs that disrupt the bacterial cell wall. Ceftriaxone is a third-generation cephalosporin.
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.