The health care provider prescribes IV vancomycin for a patient with pneumonia. Which priority action should the nurse perform before the first dose of the antibiotic?

Check the patient's temperature

Obtain sputum cultures

Check the patient's blood pressure

Draw a blood specimen to evaluate the white blood cell count

Answer and Explanation

The Correct Answer is B

Choice A reason: Checking the patient's temperature is important for assessing the severity of the pneumonia and monitoring for fever, but it is not the priority action before administering the first dose of vancomycin.

Choice B reason: Obtaining sputum cultures is the priority action because it allows for the identification of the causative organism and determination of its antibiotic susceptibility. This helps ensure that the prescribed antibiotic is appropriate for the patient's infection. Cultures should be obtained before starting antibiotic therapy to avoid interference with culture results.

Choice C reason: Checking the patient's blood pressure is important for overall patient assessment and monitoring, especially considering potential side effects of vancomycin. However, it is not the primary action needed before the first dose of the antibiotic.

Choice D reason: Drawing a blood specimen to evaluate the white blood cell count is useful for assessing the severity of the infection and the patient's immune response. However, this can be done after obtaining the sputum cultures and is not the immediate priority before administering the antibiotic.

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Correct Answer is C

Explanation

Choice A reason: Administering Furosemide (Lasix) 40 mg IV is important for reducing fluid overload, but the immediate priority is to address the patient's low oxygen saturation levels.

Choice B reason: Assessing lung sounds and peripheral edema is important for ongoing monitoring, but the immediate action should focus on stabilizing the patient's oxygen levels.

Choice C reason: Placing the patient on oxygen to titrate to oxygen saturations 94% or greater is the most immediate and critical intervention. The patient's oxygen saturation is significantly low at 86%, and addressing this ensures adequate oxygenation and reduces the risk of hypoxia.

Choice D reason: Educating the patient on lifestyle modifications is important for long-term management but is not the immediate priority in an acute situation.

A. Stage 2 B. Stage 1 C. Stage 3 D. Stage 4

Correct Answer is C

Explanation

Choice A reason: Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. Since the wound involves subcutaneous tissue, it exceeds the criteria for Stage 2.

Choice B reason: Stage 1 pressure injuries are characterized by non-blanchable erythema of intact skin. While the skin is still intact, it may appear red and not lighten when pressed. Given the description of a wound involving subcutaneous tissue, Stage 1 is not appropriate.

Choice C reason: Stage 3 pressure injuries involve full-thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible, but the depth of tissue damage varies by anatomical location. This aligns with the wound involving subcutaneous tissue.

Choice D reason: Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. While the wound described involves subcutaneous tissue, there is no mention of deeper tissue involvement, excluding Stage 4 classification.

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The health care provider prescribes IV vancomycin for a patient with pneumonia. Which priority action should the nurse perform before the first dose of the antibiotic?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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Correct Answer is C

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The health care provider prescribes IV vancomycin for a patient with pneumonia. Which priority action should the nurse perform before the first dose of the antibiotic?