The nurse is preparing to administer an aminoglycoside antibiotic to a client admitted with a diagnosis of acute diverticulitis.
What is the priority nursing action?

Monitor the peak level of the antibiotic.

Assess the client’s vital signs.

Obtain a serum trough level.

Ask the client about drug allergies.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Monitoring the peak level of the antibiotic is important, but it is not the priority nursing action. Peak levels are typically drawn after the drug has been administered and are used to assess whether the dosage is sufficient.

Choice B rationale

Assessing the client’s vital signs is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.

Choice C rationale

Obtaining a serum trough level is the priority nursing action. Trough levels are drawn just before the next dose of the drug is due and are used to assess whether the dosage is safe.

Choice D rationale

Asking the client about drug allergies is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.

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Correct Answer is D

Explanation

Choice A rationale

A serum fasting glucose of 101 mg/dL is slightly above the normal range (70-100 mg/dL), indicating a possible prediabetes condition. However, it is not a contraindication for trimethoprim-sulfamethoxazole.

Choice B rationale

A platelet count of 160,000 uL is within the normal range (150,000-450,000 uL). Therefore, it is not a contraindication for trimethoprim-sulfamethoxazole.

Choice C rationale

A hemoglobin level of 13.6 g/dL is within the normal range for both men (13.5-17.5 g/dL) and women (12.0-15.5 g/dL). Thus, it is not a contraindication for trimethoprim-sulfamethoxazole.

Choice D rationale

A serum creatinine level of 2.5 mg/dL is above the normal range (0.6-1.2 mg/dL for men, 0.5- 1.1 mg/dL for women), indicating impaired kidney function. Trimethoprim-sulfamethoxazole is contraindicated in patients with severe renal insufficiency.

A. Urine specific gravity 1.012. B. +4 Pedal pulses. C. Respiratory rate 20/minute. D. Potassium level 3.8 mEq/L.

Correct Answer is A

Explanation

Choice A rationale

Fluid Volume Excess (FVE), or hypervolemia, refers to an isotonic expansion of the ECF due to an increase in total body sodium content and an increase in total body water. This fluid overload usually occurs from compromised regulatory mechanisms for sodium and water as seen commonly in heart failure (CHF), kidney failure, and liver failure. The key signs of hypervolemia include weight gain and swelling. One of the defining characteristics of FVE is an increase in urine specific gravity. Therefore, a urine specific gravity of 1.012 can validate the problem of Fluid Volume Excess for a patient.

Choice B rationale

+4 Pedal pulses indicate a very bounding and strong pulse, which is not directly related to Fluid Volume Excess. While it might be observed in some cases due to increased blood volume and pressure, it is not a specific or primary indicator of this condition.

Choice C rationale

A respiratory rate of 20/minute is within the normal range for an adult (12-20 breaths per minute) and does not specifically indicate Fluid Volume Excess. While respiratory changes can occur with severe or prolonged Fluid Volume Excess, a normal respiratory rate does not validate this diagnosis.

Choice D rationale

A potassium level of 3.8 mEq/L is within the normal range (3.5-5.0 mEq/L) and does not specifically indicate Fluid Volume Excess. While electrolyte imbalances can occur with Fluid Volume Excess, a normal potassium level does not validate this diagnosis.

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The nurse is preparing to administer an aminoglycoside antibiotic to a client admitted with a diagnosis of acute diverticulitis. What is the priority nursing action?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly admitted client has been prescribed trimethoprim-sulfamethoxazole. The nurse understands that this medication is contraindicated based on which lab result?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse identifies the problem of Fluid Volume Excess for a patient. Which assessment finding validates this problem?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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The nurse is preparing to administer an aminoglycoside antibiotic to a client admitted with a diagnosis of acute diverticulitis.
What is the priority nursing action?