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A nurse is preparing to administer the first dose of cefazolin via intermittent Ivrder and refuses to take their medication. Which of the following nurse take first?

Assess the IV for patency.

Check the compatibility of cefazolin with the client's existing IV fluids.

Review the client's allergy history.

Obtain the reconstituted antibiotic from the pharmacy.

Answer and Explanation

The Correct Answer is C

A. Assessing IV patency is important but comes after confirming the client is not allergic.

B. Checking compatibility ensures safe administration but is not the first priority.

C. Reviewing the client's allergy history is the priority to prevent a potentially life-threatening allergic reaction.

D. Obtaining the medication is necessary but only after confirming it is safe for the client.

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Correct Answer is D

Explanation

A. Monitor vital signs every hour for the first 4 hr: Incorrect. Vital signs should be monitored more frequently, typically every 15 minutes during the first hour after administration, due to the risk of bleeding.

B. Administer medications intramuscularly: Incorrect. Intramuscular injections should be avoided while the client is on alteplase due to the increased risk of bleeding.

C. Provide a diet low in protein: Incorrect. There is no need for a low-protein diet with alteplase therapy. The focus should be on managing bleeding risks and monitoring for complications.

D. Observe for bruising of the skin: Alteplase is a thrombolytic medication, and one of its major side effects is bleeding. The nurse should monitor the client for signs of bruising, bleeding, or hemorrhage.

A. Client reports a pain level of 6 on a scale from 0 to 10 B. Excoriation of the skin on the neck and chest C. Xerostomia D. Dysphagia

Correct Answer is D

Explanation

A. Pain level of 6: Important but not life-threatening.

B. Excoriation: Requires treatment but is not the priority.

C. Xerostomia: Manageable with supportive care.

D. Dysphagia: Can lead to aspiration, malnutrition, or airway compromise and requires immediate attention.

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A nurse is preparing to administer the first dose of cefazolin via intermittent Ivrder and refuses to take their medication. Which of the following nurse take first?

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