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?
Auscultate bowel sounds.
Measure oxygen saturation.
Check serum creatinine.
Assess body temperature.
The Correct Answer is C
Choice A rationale
Auscultating bowel sounds is important for assessing gastrointestinal function, but it is not directly related to the administration of vancomycin for Clostridium difficile infection.
Choice B rationale
Measuring oxygen saturation is important for assessing respiratory function, but it is not directly related to the administration of vancomycin for Clostridium difficile infection.
Choice C rationale
Checking serum creatinine is crucial before administering vancomycin because this medication can be nephrotoxic. Monitoring kidney function helps prevent potential renal damage.
Choice D rationale
Assessing body temperature is important for monitoring infection, but it is not directly related to the administration of vancomycin for Clostridium difficile infection.
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Correct Answer is C
Explanation
Choice A rationale
Monitoring daily urine output volume is important for assessing fluid balance, but it does not directly address the issue of hypernatremia. Hypernatremia is characterized by high sodium levels in the blood, and monitoring urine output alone will not help in managing sodium intake or identifying sources of excess sodium.
Choice B rationale
Using salt tablets after strenuous exercise is not recommended for clients with hypernatremia. Salt tablets can increase sodium levels further, exacerbating the condition. Hypernatremia requires careful management of sodium intake, and salt tablets would be counterproductive.
Choice C rationale
Reviewing food labels for sodium content is crucial for clients with hypernatremia. This helps them identify and avoid foods high in sodium, which can contribute to elevated sodium levels in the blood. Educating clients on reading food labels empowers them to make informed dietary choices and manage their condition effectively.
Choice D rationale
Drinking plenty of water whenever thirsty is a general recommendation for maintaining hydration, but it does not specifically address hypernatremia. Clients with hypernatremia need to focus on managing their sodium intake and ensuring they do not consume excessive amounts of sodium.
Correct Answer is A
Explanation
Choice A rationale
Isolating the client from others is the most important action to prevent the spread of COVID-19. This includes isolating the client from other clients, family, and healthcare workers not wearing proper PPE2.
Choice B rationale
Reporting the COVID-19 result to the local health department is important but not the immediate priority. Isolation takes precedence to prevent transmission.
Choice C rationale
Teaching the client to wear a mask, hand wash, and social distance is essential but secondary to immediate isolation.
Choice D rationale
Counseling family members to monitor for symptoms is important but not the immediate priority. Isolation of the client is the first step.