A nurse is reviewing the medical record of a client who has sinusitis and a new prescription for cefuroxime. Which of the following client information is the priority for the nurse to report to the provider?

The client has a history of a severe penicillin allergy.

The client takes an aspirin daily.

The client reports a history of nausea with cefuroxime.

The client has a BUN level of 18 mg/dL

Answer and Explanation

The Correct Answer is A

A. The client has a history of a severe penicillin allergy:
Correct Answer: This is the priority information for the nurse to report to the provider.
Explanation: Cefuroxime is a cephalosporin antibiotic. Individuals with a history of severe penicillin allergy may also have an increased risk of cross-reactivity with cephalosporin antibiotics. This potential cross-reactivity needs to be evaluated by the provider to determine the safety of prescribing cefuroxime for the client.
B. The client takes an aspirin daily:
Incorrect Explanation: While the daily use of aspirin should be considered when prescribing medications, it is not the priority in this scenario.
Explanation: Aspirin use might affect bleeding risk, but it is not directly related to the potential interaction with cefuroxime. The client's severe penicillin allergy takes precedence in terms of immediate concern.
C. The client reports a history of nausea with cefuroxime:
Incorrect Explanation: A history of nausea with cefuroxime is relevant but is not as critical as the severe penicillin allergy.
Explanation: While the nurse should consider the client's history of nausea with cefuroxime, it is not as urgent as addressing the potential cross-reactivity with penicillin.
D. The client has a BUN level of 18 mg/dL:
Incorrect Explanation: The BUN level is not the priority in this context.
Explanation: A BUN level of 18 mg/dL is within the normal range and is not immediately relevant to the decision about prescribing cefuroxime.

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Correct Answer is D

Explanation

A. Decrease in protein:
This choice is incorrect. Albumin is a protein found in the blood, and when a client is receiving an infusion of albumin, it is likely to increase, not decrease, the overall protein level in the bloodstream. Albumin infusions are often given to help increase plasma oncotic pressure and improve fluid retention in conditions like shock.
B. Oxygen saturation 96%:
This choice is incorrect. Oxygen saturation of 96% is within the normal range and reflects adequate oxygenation. It doesn't directly relate to the administration of albumin in shock.
C. PaCO2 30 mm Hg:
This choice is incorrect. The partial pressure of carbon dioxide (PaCO2) of 30 mm Hg reflects a respiratory value and doesn't directly relate to the administration of albumin or the management of shock. It's important for assessing acid-base balance, but it's not a specific finding related to the albumin infusion.
D. Increase in BP:
This is the correct choice. Albumin is a colloid solution that helps increase the oncotic pressure within blood vessels, which can contribute to an increase in blood volume. When blood volume increases, it can lead to an increase in blood pressure, which is a desired effect in the management of shock. Increasing blood pressure helps improve perfusion to vital organs and tissues, which is essential in shock situations.

A. Slow the infusion rate. B. Apply pressure to the IV site. C. Elevate the extremity. D. Flush the IV catheter.

Correct Answer is B

Explanation

A. Slow the infusion rate:
Incorrect Explanation: Slowing the infusion rate is not the appropriate action when fluid infiltration has occurred.
Explanation: Fluid infiltration occurs when the IV catheter becomes dislodged from the vein and fluid enters the surrounding tissues. Slowing the infusion rate will not prevent or address this issue.
B. Apply pressure to the IV site:
Correct Answer: Applying pressure to the IV site is an appropriate initial action when fluid infiltration occurs.
Explanation: Applying gentle pressure just above the insertion site can help prevent further fluid from entering the surrounding tissues. This can help minimize the extent of infiltration and reduce potential complications.
C. Elevate the extremity:
Incorrect Explanation: Elevating the extremity is not the primary action to take when fluid infiltration is present.
Explanation: Elevating the extremity might be helpful in reducing swelling and promoting blood flow in general, but it's not the primary action to address fluid infiltration.
D. Flush the IV catheter:
Incorrect Explanation: Flushing the IV catheter is not the appropriate action for addressing fluid infiltration.
Explanation: Flushing the catheter might exacerbate the infiltration by pushing more fluid into the surrounding tissues. It's important to address the issue of infiltration first.

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A nurse is reviewing the medical record of a client who has sinusitis and a new prescription for cefuroxime. Which of the following client information is the priority for the nurse to report to the provider?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissues surrounding the insertion site. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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