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 D
Explanation
Choice A rationale
Trouble sleeping is not directly relevant to the administration of pyridostigmine, which is used to improve muscle strength in myasthenia gravis.
Choice B rationale
Unexplained weight loss is not a primary concern when administering pyridostigmine. The focus should be on the patient’s ability to swallow and recent oral intake.
Choice C rationale
Difficulty with urination is not a primary concern for pyridostigmine administration. The medication’s effects on muscle strength and swallowing are more critical.
Choice D rationale
Recent oral intake is crucial to assess because pyridostigmine can cause gastrointestinal side effects, and food intake can affect its absorption and effectiveness.
Correct Answer is A
Explanation
Choice A rationale
For long-term control of normal eye pressure is the accurate response. Open-angle glaucoma is a chronic condition that requires ongoing treatment to maintain normal intraocular pressure and prevent further damage to the optic nerve. Eye drops are typically used for life to manage the condition.
Choice B rationale
Until a smaller angle can be restored is not accurate because open-angle glaucoma does not involve a change in the angle of the anterior chamber. The goal of treatment is to lower intraocular pressure, not to restore the angle.
Choice C rationale
For long-term control of pain and swelling is not accurate because open-angle glaucoma primarily involves increased intraocular pressure and optic nerve damage, not pain and swelling. The goal of treatment is to lower intraocular pressure.
Choice D rationale
Until the excess pressure is reduced is not accurate because open-angle glaucoma requires ongoing treatment to maintain normal intraocular pressure. Stopping treatment once pressure is reduced can lead to a recurrence of elevated pressure and further damage.