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

The client reports a history of nausea with cefuroxime.

The client has a BUN level of 18 mg/dL.

The client takes an aspirin daily.

The client has a history of a severe penicillin allergy.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

A history of nausea with cefuroxime is a common side effect and may not be the highest priority to report.

Choice B rationale:

A BUN level of 18 mg/dL is within the normal range and may not be an immediate concern.

Choice C rationale:

Taking aspirin daily may have some interactions with cefuroxime, but a history of a severe penicillin allergy is more critical to report.

Choice D rationale:

Cefuroxime is a cephalosporin antibiotic, and individuals with a severe penicillin allergy may have an increased risk of cross-reactivity with cephalosporins. This history should be reported to the provider for further assessment and consideration of alternative antibiotics.

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Correct Answer is A,B,C,D

Explanation

Choice A rationale:

The first step is to remove the medication from the dispensing system. This ensures that the nurse has the right medication and dose for the client. The nurse should also check the label of the medication against the medication administration record (MAR) at this point. Choice B rationale:

The second step is to compare the client's wristband to the MAR. This verifies the client's identity and prevents medication errors. The nurse should use two identifiers, such as name and date of birth, to confirm the client's identity.

Choice C rationale:

The third step is to open the medication package. This prepares the medication for administration and prevents contamination. The nurse should also check the expiration date of the medication before opening it.

Choice D rationale:

The fourth step is to document administration of the medication. This completes the medication administration process and provides a record of the client's care. The nurse should document the medication name, dose, route, time, and any relevant observations or outcomes.

A. Weight gain B. Oliguria C. Nausea D. Headaches

Correct Answer is B

Explanation

Choice A rationale:

Weight gain is not typically associated with fluid volume deficit.

Choice B rationale:

Oliguria (reduced urine output) is indicative of fluid volume deficit, as the body conserves fluid by producing less urine.

Choice C rationale:

Nausea may be related to various factors, but it is not a specific sign of fluid volume deficit.

Choice D rationale:

Headaches can occur for various reasons and are not specific to fluid volume deficit.

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

Nursing Test Bank

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