The client receives multiple antibiotics to treat a serious infection. What will the priority assessment of the client by the nurse include?
1. Assessing blood cultures for the presence of bacteria
2. Assessing changes in stool, white patches in the mouth, and urogenital itching or rash
3. Assessing renal and liver function tests
4. Assessing whether or not the client has adequate food and fluid intake
2
Rationale 1: Assessing blood cultures is important, but not as important as assessing for superinfections.
Rationale 2: A superinfection occurs when microorganisms normally present in the body, host flora, are destroyed by antibiotic therapy. A superinfection can be lethal and should be suspected if a new infection appears while the client is receiving antibiotics. Signs of superinfection commonly include diarrhea, white patches in the mouth, urogenital itching, and presence of a blistering itchy rash.
Rationale 3: Assessing renal and liver function tests is very important but not as important as assessing for superinfections.
Rationale 4: Assessing food and fluid intake is very important but not as important as assessing for superinfections.
Global Rationale: A superinfection occurs when microorganisms normally present in the body, host flora, are destroyed by antibiotic therapy. A superinfection can be lethal and should be suspected if a new infection appears while the client is receiving antibiotics. Signs of superinfection commonly include diarrhea, white patches in the mouth, urogenital itching, and presence of a blistering itchy rash. Assessing blood cultures is important but not as important as assessing for superinfections. Assessing renal and liver function tests is very important but not as important as assessing for superinfections. Assessing food and fluid intake is very important but not as important as assessing for superinfections.
You might also like to view...
A nurse works at a health care organization that is accredited by The Joint Commission. What is the best method for this health care organization to demonstrate that it is providing quality pa-tient care?
a. Cost of care per patient day b. Number of registered nurses c. Absence of sentinel events d. Documentation audits
A nurse is teaching health interventions to an older adult with osteoarthritis. Which of these statements indicates that the individual needs additional teaching?
A) "I will avoid high-impact exercises." B) "I will get adequate intake of calcium and vitamin D." C) "I will try to limit my use of walkers and assistive devices." D) "I will lose weight if it turns out that I need to."
A home care nurse is encouraging the administration of the agency to increase their quality assurance efforts. Which of the following best describes a negative outcome from this activity?
a. An agency deficiency may become visible. b. An individual may be found at fault and then become fearful of being involved. c. Some agency processes may be questioned. d. Employees at the agency will have to commit extra time to complete this process.
The client wears contact lenses and has been prescribed eyedrops for glaucoma. What will the best education by the nurse include with regard to contact lenses?
1. Remove lenses before instilling eyedrops; do not reinsert lenses for 15 minutes. 2. Instill the drops with the contacts in as long as they are the hard kind of contacts. 3. Eyeglasses must be worn for as long as the client must have the eyedrops. 4. Instill the drops with the contacts in as long as they are the soft kind of contacts.