A nurse is contributing to the care plan for a client who has a halo vest following a cervical fracture 8 hours ago. Which intervention should the nurse recommend for inclusion in the plan?

 

Choice A rationale:

Temperature is not a contraindication to cefazolin administration. While fever or temperature might indicate an infection or other condition that needs to be addressed, it does not by itself contraindicate the use of cefazolin. Cefazolin is an antibiotic, and its administration should be based on the presence of an infection and not solely on temperature readings.

Choice B rationale:

Allergy history is a significant contraindication for administering cefazolin. If the client has a known allergy or hypersensitivity to cefazolin or other cephalosporins, administering this medication could cause a severe allergic reaction, including anaphylaxis. Always review the client's allergy history before administering any medication to avoid such adverse effects.

Choice C rationale:

WBC count, although elevated in this scenario (13,000/mm³), is not a contraindication for cefazolin administration. An elevated WBC count may suggest an infection or inflammation, which might actually indicate a need for antibiotic therapy rather than contraindicate it.

Choice D rationale:

Amylase level is within normal range (80 units/L), so it does not contraindicate cefazolin administration. Elevated or abnormal amylase levels would be more relevant to concerns about pancreatitis or other pancreatic issues, but in this case, the level does not suggest a contraindication for cefazolin.

Choice E rationale:

Prescription for furosemide is relevant to consider as a potential contraindication due to the risk of nephrotoxicity. Cefazolin and furosemide both have the potential to impact kidney function. Using these medications together may increase the risk of renal impairment, especially in patients with pre-existing renal conditions. Therefore, it's important to monitor renal function closely when these medications are used together.

Let’s analyze the data collection findings to determine if they are consistent with hypovolemic shock or pulmonary embolism:

1. Respiratory effort:
   • Hypovolemic Shock: ✔
   • Pulmonary Embolism: ✔
2. Heart rate:
   • Hypovolemic Shock: ✔
   • Pulmonary Embolism: ✔
3. Pain:
   • Pulmonary Embolism: ✔
4. Blood pressure:
   • Hypovolemic Shock: ✔
5. Mentation:
   • Hypovolemic Shock: ✔
   • Pulmonary Embolism: ✔

Each finding can support more than one condition, and there must be at least one selection in every column.