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 D

Explanation

A. Discouraging the client from allowing friends to see the newborn may deprive the client of potential sources of support and comfort during the grieving process.

B. Avoiding talking to the client about the newborn may inhibit the client's ability to process their emotions and may convey a lack of support from the nurse.
C. While it is important to provide reassurance, assuring the client that she can have additional children may minimize the client's current grief and invalidate her feelings of loss.
D. Offering to take pictures of the newborn allows the client to create lasting memories and keepsakes, which can be comforting and therapeutic during the grieving process.

A. Negligence B. Battery C. Assault D. Libel

Correct Answer is C

Explanation

A. Negligence refers to the failure to provide care that a reasonably prudent person would have under similar circumstances, resulting in harm to the patient.
B. Battery involves the intentional harmful or offensive contact with a person without their consent. While similar to assault, battery involves actual physical contact, such as forcibly inserting a urinary catheter without consent.
C. Assault occurs when a threat of harmful or offensive contact is made, causing fear or apprehension in the victim. In this scenario, the newly licensed nurse's statement of

inserting a urinary catheter without consent if the client does not void constitutes an act of assault.
D. Libel involves making defamatory statements in written or published form, which is not applicable in this scenario.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process?

Correct Answer is D

Explanation

A charge nurse is observing a newly licensed nurse provide care for a client who is postoperative. The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not vold. Which of the following torts should the charge nurse Identify as having occurred?

Correct Answer is C

Explanation

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