A client comes to the emergency department with a fever of 104 F. ...

[lilldybug07]

A client comes to the emergency department with a fever of 104 F. What will the best plan by the nurse include?
 
  1. Plan to obtain liver and renal function tests.
  2. Plan to obtain a complete blood count (CBC) test.
  3. Plan to obtain a sterile urine specimen.
  4. Plan to obtain blood for culture and sensitivity.

Question 2

The client has MRSA and receives vancomycin (Vancocin) intravenously (IV). The nurse assesses an upper body rash and decreased urine output. What is the nurse's priority action?
 
  1. Hold the next dose of vancomycin (Vancocin), and notify the physician.
  2. Obtain a stat X-ray, and notify the physician.
  3. Administer an antihistamine, and notify the physician.
  4. Obtain a sterile urine specimen, and notify the physician.

[lauravaras]

Answer to Question 1

Correct Answer: 4
Rationale 1: Liver and renal function tests will not identify the causative organism.
Rationale 2: The CBC will reveal the impact of infective agents on the immune system, but will not identify the agent.
Rationale 3: Obtaining a urine specimen is not the best method of determining this client's infective agent.
Rationale 4: A high fever is usually indicative of a systemic infection. Blood cultures are the best way of identifying the causative organism.

Answer to Question 2

Correct Answer: 1
Rationale 1: Upper body rash and decreased urine output are most likely symptoms of vancomycin (Vancocin) toxicity, so the medication should be held and the physician notified.
Rationale 2: There is no reason to obtain a chest x-ray.
Rationale 3: The nurse should collaborate with the physician regarding medications for treatment of this situation.
Rationale 4: The client's symptoms are most likely not due to a urinary tract infection, so a sterile urine specimen is not indicated.