🟥 The nurse must obtain the culture of the surgical wound before administering antibiotics to ensure accurate identification of the causative organism.

🟥 Starting antibiotics before collecting a specimen can alter bacterial growth and lead to inaccurate culture and sensitivity results, affecting appropriate treatment.

🟥 The client shows clear signs of postoperative wound infection, including purulent drainage, warmth, tenderness, and a rising temperature.

🟥 A culture is a time-sensitive intervention because the provider needs the organism identified to adjust therapy if needed.

🟥 Once the specimen is collected, the nurse should then promptly initiate ciprofloxacin to begin treating the infection.

🟥 This sequence aligns with infection control principles and evidence-based postoperative wound care.

administer oxycodone

🟥 Pain management is important but not a priority when infection assessment must occur before antibiotics.

🟥 Giving opioids first delays the critical action of collecting the culture.

administer acetaminophen

🟥 Treating fever does not address the source of infection.

🟥 Fever reduction should occur after diagnostic steps that guide treatment.

obtain BMP

🟥 A BMP is not the priority over obtaining a wound culture in a client with a suspected postoperative infection.

🟥 Laboratory screening does not replace time-sensitive culture collection.

obtain CBC

🟥 Although helpful to assess WBC count, this test does not need to occur before culture collection.

🟥 Delaying culture collection compromises diagnostic accuracy.

pack open areas of the incision

🟥 Wound care should occur only after cultures are collected and antibiotics started.

🟥 Packing is supportive care, not a priority over initiating antimicrobial therapy.

administer bisacodyl

🟥 Constipation is non-urgent and not related to the infectious process.

🟥 This does not help stabilize the client or prevent further deterioration.

🟦 Antibiotic therapy such as ciprofloxacin increases the client’s risk for developing antibiotic-resistant organisms, including methicillin-resistant Staphylococcus aureus (MRSA).

🟦 The overuse or prolonged use of antibiotics disrupts normal flora and creates an environment where resistant bacteria can thrive.

🟦 This client is receiving a 7-day course of ciprofloxacin, which contributes to bacterial resistance risk and requires patient education.

🟦 MRSA infections are harder to treat, spread more easily, and can cause serious postoperative complications.

🟦 The nurse should reinforce proper medication use, hygiene practices, and infection-prevention measures to reduce MRSA risk.

🟦 Teaching the relationship between antibiotic use and resistant organisms helps improve adherence and safety after discharge.

dry skin – hormone replacement

🟦 Hormone replacement therapy does not commonly cause dry skin; it more often improves vasomotor and skin symptoms.

🟦 This adverse effect is unrelated to the client’s current therapy.

rhinorrhea – anti-reflux

🟦 Esomeprazole (anti-reflux) does not cause rhinorrhea.

🟦 PPIs affect gastric acid secretion, not respiratory symptoms.

tachypnea – pain medication

🟦 Opioids like oxycodone decrease respiratory rate and may cause hypoventilation—not tachypnea.

🟦 This makes the pairing inappropriate.

osteoporosis – hormone replacement

🟦 Estradiol prevents bone loss and is used to reduce osteoporosis risk.

🟦 It does not increase the risk.

adverse effects related to stool softener

🟦 Docusate causes mild gastrointestinal effects, not the conditions listed.

🟦 No matching condition in the list corresponds to stool softener use.

🟪 Intranasal vitamin B₁₂ requires adequate mucosal absorption, and gentle massage of the nose helps distribute the medication across the nasal mucosa for optimal uptake.

🟪 This improves the effectiveness of therapy for clients with malabsorption syndrome, who cannot absorb B₁₂ adequately through the gastrointestinal tract.

🟪 Gentle massage also prevents medication runoff from the nostril, ensuring the full therapeutic dose is absorbed.

🟪 Intranasal formulations depend on contact time with the mucosa, making post-administration massage an important step.

🟪 Proper technique reduces risk of treatment failure and prevents recurrence of pernicious anemia symptoms.

🟪 Teaching this ensures the client achieves stable and consistent B₁₂ levels.

“Take this medication once per day.”

🟪 Intranasal vitamin B₁₂ is administered once weekly, not daily.

🟪 Daily use can cause mucosal irritation and is unnecessary for maintaining adequate B₁₂ levels.

“Drink a hot liquid after administering the medication.”

🟪 Hot liquids can increase nasal blood flow and cause medication to drain or be absorbed unevenly.

🟪 This reduces the medication’s effectiveness and is not recommended.

“Store this medication in the refrigerator.”

🟪 Intranasal vitamin B₁₂ should be stored at room temperature, not refrigerated.

🟪 Cold temperature can alter spray consistency and reduce proper delivery

🟧 Nitroglycerin patches must be applied to a different site each day to prevent skin irritation and improve medication absorption.

🟧 Rotating sites also decreases the risk of developing localized dermatitis, which can occur with repeated exposure to the same area.

🟧 Transdermal patches deliver continuous vasodilation to prevent angina attacks, and absorption can be impaired if the skin becomes irritated.

🟧 Proper site rotation allows consistent therapeutic levels and reduces complications.

🟧 Rotation also helps the nurse or client assess the skin for any adverse reactions such as redness or breakdown.

🟧 This teaching reinforces safe self-administration of long-term nitrate therapy.

Cover the patch with a dry dressing.

🟧 Covering a nitroglycerin patch can trap heat and increase systemic absorption, risking hypotension or headache.

🟧 The patch is designed to remain uncovered.

Apply another patch if experiencing chest pain.

🟧 Nitroglycerin patches are preventive, not for acute chest pain relief.

🟧 Acute pain should be treated with sublingual nitroglycerin, not an extra patch.

Leave each patch in place for 24 hr.

🟧 Nitroglycerin patches should be removed after 12–14 hours to prevent tolerance.

🟧 A nitrate-free period daily is required to maintain effectiveness.

🟦 Theophylline is a bronchodilator in the methylxanthine class, and its primary therapeutic effect is bronchial smooth muscle relaxation, which leads to bronchodilation.

🟦 This opens narrowed airways and improves airflow for clients with asthma, COPD, or other chronic respiratory conditions.

🟦 By reducing airway resistance, theophylline helps decrease work of breathing and improves oxygenation.

🟦 The medication works through phosphodiesterase inhibition, increasing cyclic AMP to maintain bronchodilation.

🟦 While it has mild anti-inflammatory properties, its main purpose remains airway dilation, not secretion thinning or leukotriene modification.

🟦 Teaching should emphasize expected breathing improvement, as well as monitoring for toxicity due to its narrow therapeutic range.

Reduces inflammation

🟦 Theophylline is not a primary anti-inflammatory medication; corticosteroids perform this function.

🟦 It cannot be relied upon to control airway inflammation in asthma.

Loosens secretions

🟦 Loosening mucus is the action of expectorants or mucolytics, not theophylline.

🟦 Theophylline does not modify mucus viscosity.

Blocks leukotrienes

🟦 This action describes leukotriene modifiers such as montelukast, not theophylline.

🟦 Theophylline does not affect leukotriene pathways.

🟩 This is particularly important because digoxin has a narrow therapeutic index.

🟩 Nausea is one of the most common gastrointestinal signs of digoxin toxicity.

🟩 Digoxin stimulates the chemoreceptor trigger zone, resulting in nausea, anorexia, or vomiting.

🟩 GI symptoms typically appear before cardiac conduction issues, making them useful early indicators.

🟩 The nurse should closely assess new GI disturbances in clients on digoxin.

🟩 Prompt recognition prevents worsening toxicity and prevents arrhythmias.

🟩 Even mild nausea in a digoxin user should trigger evaluation of serum digoxin levels.

Dysrhythmia

🟩 Dysrhythmias are the most dangerous adverse effect of digoxin and often occur in toxicity.

🟩 Digoxin increases intracellular calcium in cardiac tissue, altering AV node conduction and predisposing the client to ectopic beats or heart block.

🟩 Brady-arrhythmias, tachyarrhythmias, or AV dissociation can occur.

🟩 The nurse must carefully monitor apical pulse and rhythm before each dose.

🟩 New-onset irregular rhythms require immediate evaluation of potassium levels and serum digoxin levels.

🟩 Cardiac dysrhythmias are a leading cause of hospitalization in clients with digoxin toxicity.

Hyperactivity

🟩 Digoxin toxicity causes fatigue, weakness, and lethargy, not hyperactivity.

🟩 Increased CNS stimulation is not associated with this medication.

Increased appetite

🟩 Digoxin more commonly causes anorexia, especially early in toxicity progression.

🟩 Increased appetite is contradictory to expected effects.

🟨 Eplerenone is a selective aldosterone receptor blocker, which decreases sodium and water retention while reducing potassium excretion, placing the client at risk for hyperkalemia.

🟨 By blocking aldosterone, the distal renal tubules retain more potassium, causing serum levels to rise.

🟨 Elevated potassium can lead to dangerous cardiac conduction abnormalities, including peaked T waves, widened QRS complexes, and arrhythmias.

🟨 The nurse should routinely monitor serum potassium, especially during the first weeks of therapy or when the client is also taking ACE inhibitors or potassium supplements.

🟨 Clients should also be taught to avoid potassium-rich foods and salt substitutes containing potassium.

🟨 Early recognition of hyperkalemia prevents progression to life-threatening cardiac complications.

Hematuria

🟨 Hematuria is not associated with eplerenone therapy.

🟨 This finding typically relates to infections, stones, or renal pathology, not aldosterone blockade.

Hypernatremia

🟨 Eplerenone lowers sodium levels by promoting sodium excretion, so hypernatremia is unlikely.

🟨 Hyponatremia is a more plausible but still uncommon effect.

Constipation

🟨 Constipation is not a known adverse effect of eplerenone.

🟨 Other antihypertensives like calcium channel blockers are more likely to cause constipation.

🟥 Isoniazid (INH) is hepatotoxic, and assessing the client’s alcohol intake is essential because alcohol significantly increases the risk of liver damage during therapy.

🟥 Clients who consume alcohol daily or heavily are at the highest risk for developing isoniazid-induced hepatitis, which can progress to liver failure if not identified early.

🟥 Knowing alcohol habits helps the nurse reinforce the need for strict alcohol avoidance while taking the medication.

🟥 The nurse must also monitor for early symptoms of hepatotoxicity such as fatigue, jaundice, nausea, and dark urine.

🟥 This assessment supports safe medication therapy and prevents severe complications.

🟥 Because liver toxicity is the primary safety concern with INH, alcohol screening is a priority action.

Tell the client to expect red-orange colored urine.

🟥 Red-orange urine is an adverse effect of rifampin, not isoniazid.

🟥 Giving incorrect teaching could confuse the client about expected reactions.

Reinforce teaching about a low-calorie diet.

🟥 INH therapy does not require a low-calorie diet.

🟥 Instead, clients may need vitamin B6 (pyridoxine) supplementation to prevent neuropathy.

Instruct the client to have a yearly tuberculin skin test.

🟥 Skin testing is not needed once tuberculosis is diagnosed and treatment has started.

🟥 The test will remain positive for life and is no longer useful for evaluation.

🟪 Furosemide is contraindicated in clients with a history of Stevens-Johnson syndrome (SJS) from sulfonamide medications because furosemide is a sulfonamide-derived loop diuretic.

🟪 Clients who react severely to sulfonamide antibiotics such as sulfamethoxazole-trimethoprim are at increased risk of cross-reactivity with sulfonamide-based non-antibiotic medications.

🟪 SJS is a life-threatening hypersensitivity reaction, and even a small re-exposure to sulfa-related drugs can trigger another severe dermatologic reaction.

🟪 The nurse must recognize hidden sulfonamide ingredients in commonly used medications to prevent repeat exposure.

🟪 Furosemide should be replaced with a safer diuretic alternative if needed, such as ethacrynic acid, which does not contain sulfonamide structure.

🟪 Preventing re-exposure to sulfonamide-containing medications is a critical safety priority in clients with a past SJS episode.

Prednisone

🟪 Prednisone is a corticosteroid and does not contain sulfonamide components.

🟪 It is sometimes used to manage inflammatory reactions, not cause SJS recurrence.

Lansoprazole

🟪 Lansoprazole is a proton pump inhibitor and is not chemically related to sulfonamides.

🟪 There is no known cross-reactivity with sulfa allergies.

Digoxin

🟪 Digoxin has no sulfonamide structure and is not associated with SJS recurrence in sulfa-sensitive clients.

🟪 It is safe for use regarding sulfonamide allergy.

🟧 Exenatide is a GLP-1 agonist, and one of its most serious adverse effects is acute pancreatitis, which presents with severe abdominal pain that may radiate to the back.

🟧 This pain is often sudden, persistent, and unrelieved by antacids or rest, making it a medical emergency.

🟧 Withholding the medication prevents worsening pancreatic inflammation, which can progress to necrotizing pancreatitis if not promptly addressed.

🟧 The nurse should immediately notify the provider so diagnostic testing such as serum amylase and lipase can be obtained.

🟧 Recognizing abdominal pain as a warning sign ensures early intervention and prevents potentially life-threatening complications.

🟧 Exenatide should not be resumed until pancreatitis is ruled out or resolved.

Loss of appetite

🟧 Mild appetite reduction is a common and expected effect of GLP-1 agonists and is not typically dangerous.

🟧 This does not require withholding the dose.

Muscle weakness

🟧 Muscle weakness is not a known serious adverse effect of exenatide.

🟧 It may relate to glucose fluctuations but does not indicate pancreatitis.

Heartburn

🟧 Heartburn can occur from delayed gastric emptying, but it is not a sign of an emergency.

🟧 It does not require holding the medication unless severe or persistent.