Exhibits
A nurse is collecting data from a client who has pneumonia and a prescription for cefazolin. Which of the following findings should the nurse report to the provider prior to administering the initial dose? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)
Allergies
Temperature
Chest x-ray
WBC count
The Correct Answer is A
- Allergies: The client has a documented allergy to penicillin, and cefazolin is a first-generation cephalosporin. Cephalosporins have a similar beta-lactam structure to penicillins, and there is a potential risk of cross-reactivity. Administering cefazolin without provider clearance could result in a severe allergic reaction or anaphylaxis.
- Temperature: Although the client's temperature is elevated at 39.3° C (102.8° F), this is an expected finding in pneumonia and does not need to be reported before antibiotic administration. In fact, treating the infection may help reduce the fever.
- Chest x-ray: The chest x-ray showing left lower lobe density is consistent with a diagnosis of pneumonia and supports the need for antibiotic treatment. This finding confirms the infection in the lungs and guides the choice of antibiotic therapy. It is not a reason to withhold the prescribed medication but rather a justification for it.
- WBC count: The client’s WBC count is elevated at 16,000/mm³, which is typical in bacterial infections like pneumonia. It reflects the body's immune response and further supports the need for antibiotics rather than delaying them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ask the client's family about cultural or religious practices regarding postmortem care: Respecting the client's and family's cultural and religious preferences is an important aspect of providing dignified and individualized postmortem care. Some practices may have specific rituals that should be honored.
B. Remove the client's dentures from their mouth before rigor mortis begins: Dentures are usually placed back into the client's mouth, not removed, to maintain a natural facial appearance and support the facial structure before rigor mortis sets in.
C. Turn on all the lights in the room before the family views the client's body: Creating a calm, peaceful environment is preferred when the family views the body. Harsh lighting may feel overwhelming or intrusive during such an emotional time.
D. Position the client's bed flat without a pillow under their head: Elevating the head of the bed slightly and placing a pillow under the head can help prevent blood from pooling in the head and face, preserving a more natural appearance. Leaving the bed flat is not ideal.
Correct Answer is D
Explanation
A. Hyperglycemia: Albuterol is not prescribed to manage blood glucose levels. While it can sometimes cause a mild increase in blood glucose as a side effect, its primary therapeutic action is not directed at treating hyperglycemia or any diabetic conditions.
B. Swelling of the lips: Swelling of the lips could indicate an allergic reaction or angioedema, which is a medical emergency. Albuterol is not used to treat allergic swelling; epinephrine would be the medication of choice in managing severe allergic reactions or anaphylaxis.
C. Nausea: Albuterol is not intended to treat nausea. Although gastrointestinal upset, including nausea, can sometimes occur as a side effect of albuterol, it is not administered for the purpose of controlling nausea in clients.
D. Shortness of breath: Albuterol is a short-acting beta2-agonist that works by relaxing bronchial smooth muscle, leading to bronchodilation. It is commonly prescribed to relieve acute episodes of shortness of breath, wheezing, or bronchospasm, particularly in asthma or COPD.
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