The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?
Measure oxygen saturation.
Auscultate bowel sounds.
Assess body temperature.
Check serum creatinine.
The Correct Answer is D
Measuring oxygen saturation is not directly relevant to the administration of vancomycin or the monitoring of its potential side effects. While oxygen saturation is important to assess in patients with respiratory concerns, it does not provide information about kidney function, which is essential for safe vancomycin use.
Choice B rationale:
Auscultating bowel sounds, while a part of general abdominal assessment, is not the most crucial action before administering vancomycin. Vancomycin is not known to have significant effects on bowel motility, and its primary concern is nephrotoxicity.
Choice C rationale:
Assessing body temperature can be helpful in evaluating for infection, but it is not the most specific or sensitive indicator of vancomycin-related adverse effects. Fever can be a sign of various conditions, and it does not directly assess kidney function.
Choice D rationale:
Checking serum creatinine is the most essential action before administering vancomycin because it allows for assessment of kidney function. Vancomycin is primarily excreted by the kidneys, and impaired renal function can lead to elevated drug levels and increased risk of nephrotoxicity. By checking serum creatinine, the nurse can ensure that the patient's kidney function is adequate to safely excrete vancomycin and can adjust the dosage or frequency of administration if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Anorexia is a common symptom of cirrhosis, but it is not the most immediate concern in a client with esophageal varices.
Anorexia can result from various factors, including impaired liver function, hormonal imbalances, early satiety due to ascites,
and nausea.
While it's important to address anorexia to maintain nutritional status, it doesn't directly indicate a life-threatening
complication like bleeding varices.
Choice B rationale:
Brown, foamy urine is a characteristic of kidney problems, specifically proteinuria.
It's not directly associated with esophageal varices or their complications.
While cirrhosis can affect kidney function due to fluid imbalances and impaired filtering, brown, foamy urine wouldn't be the
primary indicator of bleeding varices.
Choice C rationale:
Clay-colored stool is a sign of biliary obstruction, which can occur in cirrhosis due to impaired bile flow.
However, it's not a direct indicator of bleeding varices.
Clay-colored stool results from a lack of bile pigments in the stool, which give it its typical brown color.
Choice D rationale:
Hematemesis, or vomiting of blood, is the most critical symptom to monitor in a client with esophageal varices.
Here's why:
Esophageal varices are enlarged, swollen veins in the esophagus that develop due to increased pressure in the portal venous
system, a common consequence of cirrhosis.
These varices are fragile and prone to rupture, which can lead to massive, life-threatening bleeding.
Hematemesis is a clear sign that variceal bleeding has occurred and requires immediate intervention.
Correct Answer is B
Explanation
A Colloidal oatmeal-based lotion: Colloidal oatmeal can help to reduce itching and swelling, all while hydrating the skin. It is often used to soothe irritated skin and can be incorporated into a skincare routine through oatmeal baths or oatmeal-infused moisturizers. However, it is typically used as a complementary treatment and may not be sufficient to manage psoriasis symptoms on its own.
B Topical corticosteroids: These are an essential tool for treating inflammatory skin conditions such as psoriasis34. They work by reducing inflammation and slowing down the production of skin cells, which helps to alleviate symptoms such as redness, itching, and scaling. Topical corticosteroids are often the first line of treatment for mild to moderate psoriasis.
C. Topical analgesics: These are primarily used to relieve pain. While they may provide some relief from discomfort associated with psoriasis, they do not address the underlying inflammation and rapid skin cell production that characterize this condition.
D Topical antifungal: Antifungal agents are typically used to treat conditions like seborrheic dermatitis and scalp psoriasis, or in areas where psoriasis involves folds in the skin, where there is an increased potential for localized infection. However, they are not typically used as a primary treatment for psoriasis.
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