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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. A client who has hearing loss with a friend interpreting: A friend interpreting does not meet the legal standards for ensuring accurate communication during informed consent. A licensed medical interpreter should be used to avoid misunderstandings and to ensure that the client fully understands the risks, benefits, and alternatives of the procedure before consenting.

B. A client who has not spoken with the provider yet: Informed consent requires that the provider explain the procedure, risks, benefits, and alternatives directly to the client. Without this discussion, the client lacks the necessary information to make an educated decision and cannot legally or ethically provide informed consent.

C. A 15-year-old client whose caregiver is not at the bedside: Minors generally cannot give legal informed consent without a parent or legal guardian present, unless specific exceptions apply (such as for emancipated minors). A 15-year-old without their caregiver present does not meet the criteria for giving valid informed consent for surgical procedures.

D. A married 16-year-old client accompanied by their spouse: A married minor is considered emancipated in most jurisdictions and can legally make healthcare decisions, including providing informed consent. Their marital status grants them the legal autonomy needed to consent to medical treatments without requiring parental involvement.

A. Demonstrate to the client how to use the signaling device. B. Explain the facility's meal schedule C. Demonstrate to the client how to use the television. D. Explain the medication administration schedule.

Correct Answer is A

Explanation

A. Demonstrate to the client how to use the signaling device: Teaching the client how to use the call light is the priority because it ensures they can easily ask for assistance, especially with limited mobility. Immediate access to help reduces the risk of falls, injury, and delays in meeting urgent needs.

B. Explain the facility's meal schedule: While it is important for the client to know when meals are served, this information does not impact their immediate safety or ability to get assistance when needed, making it a lower priority than teaching about the call light.

C. Demonstrate to the client how to use the television: Teaching about the television promotes comfort but is nonessential for safety or urgent needs. Comfort measures can be addressed after critical safety interventions have been completed.

D. Explain the medication administration schedule: Understanding medication schedules is important for client education and adherence, but ensuring the ability to call for help is more immediately critical, especially in a client with limited mobility.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a group of clients in the preoperative unit. Which of the following clients can give informed consent?

Correct Answer is D

Explanation

A nurse is assisting with the admission of a client who has limited mobility. Which of the following actions is the nurse's priority?

Correct Answer is A

Explanation

The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

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