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.

Answer and Explanation

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.

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Correct Answer is ["B","C","E","G","H"]

Explanation

A. Nausea, while uncomfortable, is a common symptom during pregnancy and should be addressed, but it is not as urgent as the other symptoms in this context.

B. The deep tendon reflex (DTR) being 3+ bilaterally indicates hyperreflexia, which can be associated with conditions like preeclampsia, hence the need for follow-up.
C. The elevated blood pressure reading of 148/94 mm Hg is indicative of hypertension, which could be a sign of preeclampsia, a serious pregnancy complication.
D. The fetal heart tracing, while important, does not show immediate concern with a rate of 140/min, which is within normal limits.
E. The weight gain of 0.68 kg (1.5 lb) within the last week is significant and could be indicative of fluid retention, which is concerning in the context of the client's other symptoms.
F. The respiratory rate of 20/min falls within the normal range, and there are no other indications of respiratory distress or abnormalities in the assessment findings provided. Therefore, respiratory assessment is not a priority for follow-up at this time.
G. The fundal height measurement of 29 cm is appropriate for 30 weeks of gestation, but given the other symptoms, it should be monitored for any rapid changes.
H. The presence of 1+ dependent edema noted bilaterally suggests fluid retention, which is a concerning finding and warrants further assessment to evaluate for signs of preeclampsia or other complications.

A. "The client is exceptionally clingy to others." B. "The client might act seductively." C. "The client exhibits impulsive behavior." D. "The client is overly concerned about minor details."

Correct Answer is C

Explanation

A. Borderline personality disorder is characterized more by unstable and intense interpersonal relationships rather than clinginess.
B. While some individuals with borderline personality disorder may exhibit manipulative behaviors, this does not universally manifest as seductiveness.
C. Impulsivity, such as reckless spending or substance abuse, is a hallmark feature of borderline personality disorder, making it a crucial aspect to include in education about the condition.
D. Borderline personality disorder is not typically associated with excessive concern about minor details; instead, it's marked by a pattern of instability in mood, self- image, and behavior.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation Exhibits Select the 5 findings that require follow up by the nurse

Correct Answer is ["B","C","E","G","H"]

Explanation

A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

Correct Answer is C

Explanation

Exhibits Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.

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