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.
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Related Questions
Correct Answer is B
Explanation
A. Directing statements to the interpreter rather than the client can create a communication barrier and undermine the client's autonomy and involvement in the conversation.
B. Speaking in a normal voice at a natural pace allows the interpreter to accurately convey the message to the client without feeling rushed or overwhelmed, facilitating effective communication.
C. Pausing in the middle of sentences can disrupt the flow of communication and make it difficult for the interpreter to accurately translate the message.
D. While gestures can complement verbal communication, relying solely on gestures may lead to misinterpretation or misunderstanding, especially if cultural differences exist between the nurse, client, and interpreter.
Correct Answer is C
Explanation
A. Both fontanels show molding. Molding is seen immediately after birth due to the passage through the birth canal and should not be present at 8 months.
B. The posterior fontanel is open. The posterior fontanel usually closes by 2 to 3 months of age.
C. For an 8-month-old infant, it is normal for the anterior fontanel to still be open. It typically closes between 12 to 18 months of age.
D. Both fontanels are the same size. The anterior and posterior fontanels are naturally different sizes; the anterior is larger.
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