Which nursing action should be implemented before the prescribed levofloxacin is administered?

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Terms in this set (19)

Which assessment is most important for the nurse to complete next?

Auscultate breath sounds.
This is the highest priority because Mr. Johnson is clearly exhibiting respiratory distress

Which assessment finding supports Mr. Johnson's diagnosis of pneumonia?

Pulse rate of 110.
Tachycardia is consistent with an infectious process. In addition, Mr. Johnson's fever and rapid respiratory rate are also vital sign findings that indicate a problem, such as an infection

These ABG results indicate that Mr. Johnson is experiencing which acid base imbalance?

Respiratory acidosis.
The low pH indicates that acidosis is present. The elevated pCO2 indicates that the problem is respiratory in nature. Clients with any condition that depresses respirations are prone to the development of respiratory acidosis. Even though Mr. Johnson has a rapid respiratory rate, his underlying COPD causes the retention of CO2

Which nursing diagnosis has the highest priority when the nurse is planning care for Mr. Johnson? I

Ineffective airway clearance
There are adventitious breath sounds present, tachypnea, changes in depth of respirations, fever, and cough, which support this as a priority diagnosis. Additional priority diagnoses are impaired gas exchange and ineffective breathing patterns. Impaired gas exchange is reflected in Mr. Johnson's hypercapnia and hypoxia. The diagnosis of ineffective breathing pattern is supported by his tachypnea, use of accessory muscles, and changes in the depth of respiration.

Which nursing action should be implemented before the prescribed levofloxacin is administered?

Obtain a sputum culture.
The sputum specimen should be obtained prior to initiation of the first dose of antibiotics. Since levofloxacin is a broad-spectrum bactericidal antibiotic, it is likely to be effective against the causative organism. Once the culture and sensitivity results are obtained, a different antibiotic may be used if necessary. Another important nursing intervention is assessment of Mr. Johnson for previous allergic reactions to antibiotics

The levofloxacin 500 mg IVPB is supplied in 100 mL of D5W to be delivered over 60 minutes. There is no IV pump available so the nurse will infuse the antibiotic by gravity. The drop factor on the tubing is 20 gtts/mL. The nurse should set the IVIVPB to infuse at how many gtts per min? (Enter numerical value only. If rounding is necessary, round to the whole number.)

33
V x gtt factor/time (minutes)
100 mL x 20 min/60 min = 33.33 (33 rounded to whole number)

While Mr. Johnson is undergoing nebulizer treatments with albuterol, it is most important for the nurse to perform which assessment?

Monitor pulse and BP.
Albuterol (Ventolin) is a beta-adrenergic agonist with a bronchodilating effect. Because adrenergic agonists mimic sympathetic stimulation, Mr. Johnson must be monitored carefully for cardiac arrhythmias, hypertension, nervousness, and restlessness

After observing Mr. Johnson, which instruction by the nurse is most important for client teaching? Select all that apply

-Wait at least 5 minutes between each medication."
Mr. Johnson should wait at least 5 minutes before using the second medication.

-"Wait at least 1 minute between each puff of the same medication."
Mr. Johnson should wait 1 to 2 minutes between each puff of the same medication. In addition, he should be instructed to wait 5 minutes before using the second medication.

Which instruction should the nurse provide Mr. Johnson for an acute episode of asthma?

"Use the albuterol inhaler for acute asthma attacks."
Albuterol is a bronchodilator that is used for acute asthmatic attacks.

After checking the sensor site to make sure the readings are accurate, the nurse should then initiate which intervention?

Assess the client's respiratory rate and rhythm.
This is an acceptable oxygen saturation level for a client with COPD. The first action by the nurse is to assess the client's respiratory status and observe his effort of breathing

While taking the client's blood pressure, the nurse observes the reading on the pulse oximeter to be fluctuating from 60 to 80. Which action should the nurse implement to ensure accurate oxygen saturation readings with the pulse oximeter?

Assess the adequacy of circulation prior to applying the sensor.
The sensor will provide the most accurate reading if circulation is adequate. At regular intervals, the nurse should assess circulation and move the sensor to a new site.

Which statement by the nurse promotes effective communication with Mr. Johnson?

"You seem pretty upset this morning."
This statement allows an opportunity for Mr. Johnson to clarify his feelings.

What is the nurse's best response?

Remain silent.
This is the best choice. Silence can be a very effective communication technique. The nurse should express interest nonverbally when silence is used.

What is the best nursing action?

Instruct the UAP involved regarding the inappropriate removal of the nasal cannula.
Helping Mr. Johnson to the commode is an appropriate action for a UAP to perform, but this UAP requires some additional instruction and individual supervision with oxygen equipment..

The National Council of State Boards of Nursing has defined five rights of delegation. Which one of these rights was violated in this situation?

Right Direction/Communication.
Since continuous oxygenation was a high priority for this client, the nurse's directions to the UAP should have emphasized the need for the nasal cannula to be left on the client at all times, especially during any activity. The fifth right, Right Supervision includes direction/guidance, evaluation/monitoring, and follow-up.

Which intervention should the nurse initiate immediately?

Place resuscitation equipment in the room.
This is a high priority because Mr. Johnson's O2 saturation is dangerously low. The nurse should also prepare to transfer Mr. Johnson to the critical care unit for close monitoring

Which ethical principle is most important for the nurse to consider when responding to the son?

Autonomy.
This ethical principle refers to the individual's right to make his own decisions regarding his care. It is an important principle, which would be violated if the nurse allowed the son to play hypnosis tapes without his father's knowledge or consent.

Which outcome statement is the best indicator that Mr. Johnson's pneumonia is resolved and he is ready to be discharged?

Sputum culture is negative.
This is a significant indicator that the pneumonia is resolved.

Which additional discharge instructions should the nurse include in the teaching plan to promote optimal health for Mr. Johnson? Select all that apply

-Avoid crowds and people with infections.
This is an important measure to avoid future infections. Mr. Johnson should also be encouraged to get an annual pneumonia vaccine.

-Increase intake of oral fluids.
Mr. Johnson needs to increase his oral fluid intake to maintain adequate hydration and keep respiratory secretions thin.

-Store prescribed inhalers away from extreme heat and cold.
Extreme heat and cold can alter the composition of the inhaler medication and render it ineffective

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