A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?
“I can adjust the time and schedule for when it’s convenient for you.”.
“I can start the medication 30 minutes earlier.”.
“I have up to 2 hours after the usual schedule time to give you this medication.”.
“I can infuse the medication at a faster rate.”.
The Correct Answer is C
The correct answer is choice b. “I can start the medication 30 minutes earlier.”.
Choice A rationale:
Adjusting the time and schedule for convenience is not appropriate for medications like vancomycin, which require precise timing to maintain therapeutic levels and avoid resistance.
Choice B rationale:
Starting the medication 30 minutes earlier is a reasonable adjustment that maintains the medication’s effectiveness and safety.
Choice C rationale:
Administering the medication up to 2 hours after the usual schedule time is incorrect because it could lead to subtherapeutic levels and reduced effectiveness.
Choice D rationale:
Infusing the medication at a faster rate is unsafe as it increases the risk of adverse reactions, such as "red man syndrome".
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Exercise can help stimulate bowel movements and prevent constipation, which is a common side effect of opioid medications. Exercise can also improve blood circulation, reduce stress, and enhance mood, which can benefit clients who have chronic pain.
Choice A is wrong because decreasing insoluble fiber intake can worsen constipation. Insoluble fiber adds bulk to the stool and helps it pass more easily through the colon.
Clients who take opioid medications should increase their intake of insoluble fiber from sources such as whole grains, fruits, vegetables, nuts, and seeds.
Choice C is wrong because drinking less water can lead to dehydration and hardening of the stool, which can make it more difficult to pass.
Clients who take opioid medications should drink plenty of water to keep the stool soft and moist.
Choice D is wrong because taking a laxative every day can cause dependence, tolerance, and electrolyte imbalance.
Laxatives should be used only as a last resort and under the guidance of a health care provider.
Clients who take opioid medications should try other methods of preventing constipation first, such as increasing exercise, fiber, and water intake.
Correct Answer is A
Explanation
This is because boundaries can help the client and family to respect each other’s roles, needs, and preferences, and to avoid role confusion, resentment, or guilt. Boundaries can also promote independence and self-care for the client, as well as prevent caregiver burnout for the family.
Choice B is wrong because minimizing open discussion regarding the changes can lead to misunderstanding, frustration, or isolation. The client and family should communicate openly and honestly about their feelings, expectations, and challenges, and seek support when needed.
Choice C is wrong because authoritative communication from the adult child can create a power imbalance, undermine the client’s autonomy and dignity, or cause conflict or resistance. The client and family should use respectful and collaborative communication, and involve the client in decision-making as much as possible.
Choice D is wrong because decreasing socialization with extended relatives can reduce the client and family’s support network, increase their stress or loneliness, or limit their opportunities for meaningful activities. The client and family should maintain contact with their relatives and friends, and participate in social or recreational activities that they enjoy.
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