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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?

A.

Auscultate bowel sounds.

B.

Measure oxygen saturation.

C.

Check serum creatinine.

D.

Assess body temperature.

Answer and Explanation

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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View Related questions

Correct Answer is C

Explanation

Choice A rationale

Anxiety and grieving are important issues but are not the priority when the client is at risk for aspiration.

Choice B rationale

Chronic pain is significant, but the immediate risk of aspiration due to dysphagia takes precedence.

Choice C rationale

Risk for aspiration related to difficulty swallowing is the priority nursing problem. Aspiration can lead to serious complications such as pneumonia.

Choice D rationale

Imbalanced nutrition is important but is secondary to the immediate risk of aspiration.

Correct Answer is D

Explanation

Choice A rationale

Laying down on each side with knees bent and breathing from the abdomen is not an effective technique for improving gas exchange in emphysema patients.

Choice B rationale

Increasing the breathing rate for a full 30 seconds can lead to hyperventilation and is not recommended for improving gas exchange.

Choice C rationale

Raising hands above the head to expand the diaphragm is not a recognized technique for improving gas exchange in emphysema patients.

Choice D rationale

Drawing air in through the nose and exhaling slowly through pursed lips is an effective technique for improving gas exchange in emphysema patients. This method helps to keep the airways open longer and improves the removal of trapped air.

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