A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin?
Give the dose over 60 min.
Administer the medication undiluted.
Inject 19% lidocaine prior to each dose.
Obtain a trough level 30 min after the medication infusion.
The Correct Answer is A
A. Administering vancomycin over a longer infusion time, such as 60 minutes, can help reduce the risk of adverse reactions, such as red man syndrome or nephrotoxicity. Slower infusion rates allow for better tolerance of the medication.
B. Vancomycin should be diluted appropriately before administration to reduce the risk of infusion-related reactions.
C. Lidocaine is not typically used prior to vancomycin administration. The use of lidocaine would be more relevant for local anesthesia, not for systemic medication administration like vancomycin.
D. Trough levels are typically obtained just before the next dose of vancomycin is due, not immediately after the infusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: This could be a sign of preeclampsia, a serious condition that requires immediate medical attention due to its potential to cause high blood pressure, proteinuria, and seizures, affecting both the mother and fetus.
B: Urinary frequency is common in early pregnancy due to hormonal changes and pressure on the bladder from the growing uterus; it's not typically a concern unless accompanied by pain or other symptoms.
C: Faintness upon rising can be related to changes in blood pressure or blood volume during pregnancy, but it's not specific to the second trimester and is often transient.This can often be managed with lifestyle modifications such as rising slowly, staying hydrated, and avoiding prolonged standing.
D: Bleeding gums are also a common symptom due to hormonal changes increasing blood flow to the gums, and while it should be monitored, it is not typically a cause for alarm unless accompanied by other symptoms.
Correct Answer is ["B","C","E","F"]
Explanation
A. While it's important to assess pedal pulses regularly, there is no indication in the scenario that the pedal pulses are abnormal or require immediate follow-up. The description mentions bilateral pedal pulses being present and intact throughout both days, suggesting no acute issues with peripheral circulation.
B. Crackles heard at the bases indicate possible pulmonary complications such as atelectasis or pneumonia, requiring further assessment and intervention.
C. A heart rate of 112/min indicates tachycardia, which could be a sign of pain, anxiety, or underlying cardiovascular issues. Further evaluation is needed to determine the cause.
D. The scenario states that the movement and sensation of the right foot are intact, with warm skin and no change in pigmentation. There are no signs of compromised neurovascular status in the right foot based on the provided information, so immediate follow-up for this finding is not necessary.
E. A respiratory rate of 28/min is elevated, suggesting respiratory distress or inadequate ventilation. Prompt assessment and intervention are necessary to address any respiratory issues.
F. A pulse oximetry reading of 88% on room air indicates hypoxemia, which requires immediate attention to ensure adequate oxygenation. Further assessment and intervention are needed to improve oxygen saturation levels.
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