A nurse is preparing to administer vancomycin 500 mg via intermittent IV infusion every 6 hr. Available is vancomycin 500 mg in 0.9% sodium chloride 100 mL to infuse over 2 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.).

Choice A rationale:

While the abbreviation "MSO4" represents morphine sulfate, it is safer to spell out the medication name to prevent misinterpretation. Also, the use of "cc" for volume and lack of clarity in timing make this option less desirable.

Choice B rationale:

(Correct Choice) This option correctly identifies the medication, includes the dose (4 mg), specifies the route (IV), indicates the timing (daily at 0900 before dressing changes), and provides instructions for dilution (5 mL of sterile water).

Choice C rationale:

Using "Q.D." is an abbreviation for "every day" and might lead to confusion due to unfamiliarity. Additionally, using "cc" instead of "mL" and lack of clarity in timing reduce the accuracy of this transcription.

Choice D rationale:

Using "MSO4" and "cc" are potential sources of confusion. Also, the abbreviation "@9 AM" might not be universally understood, and "mL" is a more appropriate unit for volume.

Choice A rationale:

Delegating the task of administering a rectal suppository to an assistive personnel (AP) is appropriate because it falls within their scope of practice and does not require advanced nursing knowledge. The administration of a rectal suppository is a routine procedure that does not involve complex assessment or critical thinking. Assistive personnel are trained to perform tasks that are repetitive and do not involve making clinical judgments.

Choice B rationale:

Instructing a postoperative client to use an incentive spirometer is a nursing intervention that requires providing education and assessing the client's understanding. The nurse should directly perform this task to ensure proper technique and address any questions or concerns the client might have. This task involves patient education and therapeutic communication, making it more appropriate for the nurse.

Choice C rationale:

Measuring blood glucose using a monitor for a client who has diabetic ketoacidosis involves collecting clinical data that requires interpretation and immediate action based on the client's condition. Diabetic ketoacidosis is a serious complication that demands timely and accurate monitoring, so the nurse should perform this task to ensure correct interpretation of the results and prompt intervention if necessary.

Choice D rationale:

Using a pulse oximeter to measure oxygen saturation for a client who is ready for discharge involves assessing the client's respiratory status and determining their readiness for discharge. This task requires clinical judgment and the ability to interpret the results within the context of the client's overall condition. The nurse should perform this task to ensure that the client is safe to be discharged.