the nurse is preparing to administer iv vancomycin to a client which of the following nursing actions should be taken first
Logo

Nursing Elites

NCLEX-PN

Nclex Exam Cram Practice Questions

1. The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions should be taken first?

Correct answer: D

Rationale: Before administering any medication, including IV Vancomycin, it is crucial to ensure that the client is not allergic to the medication. This is the most critical action to prevent any potential allergic reactions. While performing a physical assessment is important, it may not be as time-sensitive as checking for allergies. Obtaining lab values related to renal function is also significant with Vancomycin due to its potential nephrotoxicity, but ensuring the client's safety by checking for allergies takes precedence. Reviewing peaks and troughs is important for monitoring drug levels, but it is a secondary step compared to checking for allergies prior to administration.

2. A 10-year-old boy has been diagnosed with a congenital heart defect. Which of the following clinical signs does not indicate CHF?

Correct answer: D

Rationale: Compulsive behavior is not a clinical sign typically associated with congestive heart failure (CHF). CHF commonly presents with symptoms such as increased body weight due to fluid retention, elevated heart rate as the heart works harder to pump blood effectively, and lower extremity edema caused by fluid buildup. While behavioral changes can occur in response to illness, compulsive behavior is not a typical indicator of CHF. Choices A, B, and C are more commonly linked to CHF and should be monitored in patients with this condition.

3. After receiving a recent tattoo, someone should be screened for:

Correct answer: C

Rationale: After receiving a recent tattoo, screening for hepatitis is crucial due to the risk of blood-borne hepatitis B or C if strict sterile procedures are not followed during the tattooing process. Tuberculosis is an airborne pathogen and is not directly related to receiving a tattoo. Herpes and syphilis are infections spread through direct contact, such as sexual contact, and are not typically associated with tattooing.

4. In which of the following conditions might increased cortisol levels be found?

Correct answer: A

Rationale: Cushing's syndrome is characterized by increased cortisol levels due to the overproduction of cortisol by the adrenal glands. This excess cortisol can lead to various symptoms and complications. Addison's disease is associated with decreased cortisol levels as it results from adrenal insufficiency, making it an incorrect choice in this context. Renal failure and congestive heart failure are not typically linked to abnormal cortisol levels, further indicating that they are not the conditions where increased cortisol levels are found.

5. A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, 'I don't want a bath. I've been up all night, and I'm clean enough.' The student reports the client's refusal to the nurse. Which action by the nurse is appropriate?

Correct answer: B

Rationale: The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client's decision. Therefore, the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate as they violate the client's rights. Informing the health care provider of the refusal of care can be discussed with the client if needed, but the immediate action should be to respect the client's wishes and allow them to rest.

Similar Questions

When a drug is listed as Category X and prescribed to women of child-bearing age/capacity, the nurse and the interdisciplinary team should counsel the client that:
Which situation is an example of the use of evidence-based practice in the delivery of client care?
What does carrying a donor card for organ donation mean?
A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client's needs at this time?
What are the hazards of improper splinting?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses