A nurse is collecting data from a client who is receiving vancomycin for a Clostridium difficile infection.
Which of the following findings is the priority for the nurse to report to the provider?
Two loose stools in the past 24 hr.
WBC 11,000/mm³.
Heart rate 104/min.
Creatinine 3.1 mg/dL.
The Correct Answer is D
Choice A rationale:
Two loose stools in the past 24 hours could be a symptom of Clostridioides difficile infection, but it’s not necessarily a priority finding. The infection can cause diarrhea, but it’s not life-threatening.
Choice B rationale:
A WBC count of 11,000/mm³ is slightly elevated, indicating a possible infection. However, it’s not necessarily a priority finding as it’s not significantly high.
Choice C rationale:
A heart rate of 104/min is slightly elevated, indicating possible stress or anxiety. However, it’s not necessarily a priority finding as it’s not significantly high.
Choice D rationale:
Creatinine level of 3.1 mg/dL is significantly high, indicating possible kidney damage, which can be a side effect of vancomycin treatment. This should be reported to the provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Sublingual nitroglycerin should be taken without water. The tablet should be placed under the tongue and allowed to dissolve.
Choice B rationale:
It is recommended to take sublingual nitroglycerin before activities that might cause angina.
Choice C rationale:
The maximum recommended dosage is three tablets within 15 minutes, not four.
Choice D rationale:
Sublingual nitroglycerin should not be chewed. It should be allowed to dissolve under the tongue.
Correct Answer is B
Explanation
Choice A rationale:
Fever is not a common side effect of acetaminophen. In fact, acetaminophen is often used to reduce fever.
Choice B rationale:
Jaundice, which is a yellowing of the skin or eyes, can be a sign of liver damage, a rare but serious side effect of acetaminophen.
Choice C rationale:
Diarrhea is not a common side effect of acetaminophen.
Choice D rationale:
Tinnitus, or ringing in the ears, is not a common side effect of acetaminophen.
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