A nurse is caring for a client who has an allergy to penicillin. The health care provider has prescribed amoxicillin. Which of the following actions should the nurse take?
Discuss the prescription with the health care provider.
Administer the medication as prescribed.
Place an incident report in the medical record.
Call the pharmacist for clarification of the medication contraindications.
The Correct Answer is A
Choice A reason: Discussing the prescription with the provider is critical, as amoxicillin, a penicillin derivative, is contraindicated in clients with penicillin allergies due to risk of anaphylaxis. This ensures patient safety by verifying or correcting the order, aligning with nursing advocacy and safety protocols, making it correct.
Choice B reason: Administering amoxicillin to a client with a penicillin allergy risks severe allergic reactions, including anaphylaxis, violating patient safety principles. Nurses must verify contraindicated orders before administration, making this action dangerous and incorrect in this scenario.
Choice C reason: Placing an incident report is premature, as no error has occurred yet. The nurse’s role is to prevent harm by addressing the contraindicated prescription proactively. This action does not resolve the issue and is inappropriate as the first step, making it incorrect.
Choice D reason: Calling the pharmacist for clarification is less direct than discussing with the provider, who issued the order. While pharmacists can provide guidance, the provider must confirm or change the prescription to ensure safety, making this action secondary and less effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: High-osmolarity formulas may cause diarrhea but are not directly linked to aspiration risk. Aspiration results from improper positioning or reflux, not formula osmolarity, so this factor is less relevant, making it incorrect for identifying aspiration risk in enteral feedings.
Choice B reason: Sitting in high-Fowler’s position (60-90 degrees) reduces aspiration risk by promoting gastric emptying and preventing reflux during enteral feedings. This is a protective measure, not a risk factor, making it incorrect for this scenario.
Choice C reason: A residual of 65 mL 1 hour postprandial is within acceptable limits (<100-200 mL, per facility protocol) and does not indicate high aspiration risk. Elevated residuals may suggest delayed emptying, but this value is normal, making it incorrect.
Choice D reason: A history of gastroesophageal reflux disease increases aspiration risk, as reflux can allow gastric contents to enter the airway during enteral feedings. This condition compromises esophageal sphincter function, making it a significant risk factor and the correct choice.
Correct Answer is D
Explanation
Choice A reason: Maternal fever may cause fetal tachycardia, not bradycardia, as it increases metabolic demand. While fever can indicate infection, it does not directly lower FHR to 100/min, making it an incorrect cause for sustained fetal bradycardia in this scenario.
Choice B reason: Chorioamnionitis, an intrauterine infection, typically causes fetal tachycardia due to stress and inflammation, not bradycardia. While serious, it does not align with a sustained FHR of 100/min, making it incorrect for this fetal condition.
Choice C reason: Maternal hypoglycemia may cause fetal distress, but it is more likely to result in tachycardia or variable decelerations, not sustained bradycardia. Its impact on FHR is less direct, making it an incorrect primary cause for this finding.
Choice D reason: Fetal anemia reduces oxygen-carrying capacity, leading to sustained bradycardia (FHR <110/min) due to hypoxia. This condition, often from hemolytic disease or bleeding, directly causes low FHR, requiring urgent evaluation, making it the correct cause.
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