A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a client.
Which of the following actions should the nurse take first?

Obtain the reconstituted antibiotic from the pharmacy.

Review the client's allergy history.

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

Assess the IV for patency.

Answer and Explanation

The Correct Answer is B

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Correct Answer is A

Explanation

Choice A rationale:

The anterior fontanel is open in an 8-month-old infant. The anterior fontanel, located at the top of the baby's head where the skull bones have not yet fused, typically closes between 12 to 18 months of age. It is a normal finding in an 8-month-old infant.

Choice B rationale:

The posterior fontanel closes earlier than the anterior fontanel, usually within the first few months of life. It is a smaller diamond-shaped area located at the back of the baby's head. It is not expected to be open in an 8-month-old infant.

Choice C rationale:

Molding refers to the shaping of the fetal head during passage through the birth canal. It can cause temporary changes in the shape of the baby's skull. By 8 months of age, molding is not an expected finding as the skull bones have had time to return to their normal shape.

Choice D rationale:

Both fontanels being the same size is not a typical finding. The anterior fontanel is larger than the posterior fontanel, and their sizes are proportional. Any significant deviation from this proportion could indicate abnormal skull development and should be further assessed.

A. Check the client's condition after the procedure. B. Assist the client to ambulate for the first time following the procedure. C. Witness the client's signature on the consent for the procedure. D. Give the client atropine 30 min before the procedure.

Correct Answer is B

Explanation

The correct answer is B.

Choice A reason: Checking the client’s condition after the procedure involves assessment, which is a critical component of the nursing process. This task requires clinical judgment and knowledge of potential complications, which are responsibilities that cannot be delegated to assistive personnel.

Choice B reason: Assisting with ambulation is a task that can be safely delegated to assistive personnel. It is a basic care task that does not require clinical judgment and can be performed under the supervision of a nurse.

Choice C reason: Witnessing a client’s signature on the consent for the procedure is a legal and ethical responsibility that involves ensuring the client understands the procedure and is giving informed consent. This task requires a level of professional accountability that is beyond the scope of assistive personnel.

Choice D reason: Administering medication, such as atropine 30 minutes before the procedure, is a nursing intervention that requires knowledge of pharmacology and the ability to monitor for adverse effects. This is not within the scope of practice for assistive personnel and must be performed by licensed nursing staff.

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A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a client. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is B

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A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a client.
Which of the following actions should the nurse take first?