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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice Arationale:
Using PCA does not necessarily increase the client’s risk of toxicity. PCA allows the client to self-administer preset doses of pain medication, which can lead to better pain control with less risk of overdose.
Choice B rationale:
Diarrhea is not a common adverse effect of morphine. Constipation, not diarrhea, is a common side effect due to slowed gastrointestinal motility.
Choice Crationale:
Checking the client’s pain level every 8 hours is not sufficient when using PCA. Pain levels should be assessed more frequently, ideally before and after each administration of the medication. This allows for timely adjustments to the medication regimen if needed.
Choice D rationale:
Instructing the client’s visitors not to operate the PCA pump is crucial. Only the patient should administer doses to prevent overdose.
Correct Answer is B
Explanation
Choice A rationale:
While it’s important for the client to maintain a balanced diet, consuming a lot of protein with each meal does not specifically benefit a person taking levodopa/carbidopa for Parkinson’s disease.
Choice B rationale:
Levodopa/carbidopa can cause side effects such as uncontrolled muscle movements in the face, arms, legs, or trunk. Therefore, monitoring for an increase in unusual movements is a sign of understanding the potential side effects of the medication.
Choice C rationale:
Levodopa/carbidopa helps manage the symptoms of Parkinson’s disease but does not prevent the disease from progressing.
Choice D rationale:
While levodopa/carbidopa can help reduce symptoms such as stiffness and tremors, it does not typically result in a rapid improvement in condition.
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