A nurse is preparing to administer a new prescription for ampicillin 1.5g IV every 6 hr to a client who has an upper respiratory infection. The client also has a prescription for a sputum specimen for culture and sensitivity. Which of the following actions should the nurse plan to take? (Select all that apply.)

Verify the prescription.

Administer the medication at 1000, 1400, 1800, and 2200.

Assess the client for an allergy to penicillin

Document giving the medications

Obtain a sputum for culture and sensitivity

Answer and Explanation

Correct Answer : A,C,D,E

The nurse should plan to take the following actions:

A.Verify the prescription: Before administering any medication, the nurse must verify the prescription to ensure accuracy, appropriateness, and that it matches the provider's order.

Regarding option B, administering the medication at 1000, 1400, 1800, and 2200 may not be appropriate. The prescription states that ampicillin should be administered every 6 hours. The nurse should administer the medication at equally spaced intervals throughout the day. If the medication is prescribed every 6 hours, the appropriate administration times would be 0600, 1200, 1800, and 2400. However, the question does not provide sufficient information to determine the exact administration times, so option B cannot be definitively selected.

C. Assess the client for an allergy to penicillin: Since ampicillin is a penicillin-class antibiotic, it is essential for the nurse to assess the client for any history of allergies to penicillin or other beta-lactam antibiotics. A penicillin allergy could lead to a severe allergic reaction, so it is crucial to identify any potential allergies before administering the medication.

D. Document giving the medications: After administering the ampicillin, the nurse should document the administration in the client's medical record, including the time, dose, route, and any relevant observations or assessments.

E. Obtain a sputum for culture and sensitivity: The client's new prescription for ampicillin may be related to an infection. To ensure appropriate and effective treatment, obtaining a sputum specimen for culture and sensitivity is necessary. This will help identify the specific bacteria causing the respiratory infection and determine which antibiotics will be most effective in treating it.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

TPN is a form of nutrition given intravenously to provide essential nutrients when a client is unable to consume an adequate oral diet. One of the potential adverse effects of TPN is fluid overload, which can manifest as peripheral edema. The presence of 2+ peripheral pitting edema indicates the accumulation of excess fluid in the tissues. It is important for the nurse to monitor the client's fluid balance closely and assess for signs of fluid overload, such as edema, to prevent complications.

A. Calcium gluconate B. Calcitonin C. Magnesium oxide D. Magnesium sulphate

Correct Answer is A

Explanation

A client with a magnesium level of 3.2 mEq/L has a higher-than-normal magnesium level, indicating hypermagnesemia. The nurse should expect to administer calcium gluconate.

Calcium gluconate is the antidote for hypermagnesemia, as it works to antagonize the effects of magnesium on the body. By administering calcium gluconate, the nurse can help counteract the effects of excess magnesium and normalize the client's magnesium levels.

Let's go through the other options:

B. Calcitonin: Calcitonin is not used to treat hypermagnesemia. Calcitonin is a hormone that regulates calcium and phosphorus levels in the body. It is used in certain conditions, such as hypercalcemia (high calcium levels), but it is not indicated for hypermagnesemia.

C. Magnesium oxide: Magnesium oxide is a form of magnesium supplement, and it is not appropriate for a client with hypermagnesemia, as it would further increase the magnesium level, exacerbating the condition.

D. Magnesium sulphate: Magnesium sulfate is also not appropriate for a client with hypermagnesemia, as it would further elevate the magnesium levels in the body. Magnesium sulfate is often used to treat magnesium deficiency or as a tocolytic agent to prevent premature labor.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as an adverse effect of TPN

Correct Answer is D

Explanation

A nurse is caring for a client who has a magnesium level of 3.2 mEq/L. Which of the following medications should the nurse expect to administer?

Correct Answer is A

Explanation

A nurse in the PACU is caring for a client who received isoflurane. Which of the following assessments is the nurse's priority?

A nurse is caring for a client who is receiving meperidine. Which of the following is the nurse's priority assessment before administering the medication?

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A nurse is assessing a client who is experiencing an anaphylactic reaction to an antibiotic. Which of the following manifestations of anaphylaxis should the nurse expect?

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A nurse is caring for a client who has anxiety and a prescription for oral lorazepam PRN. Which of the following is the correct way to transcribe the prescription into the electronic medical record?

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