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: This is an inappropriate response, as the nurse should not adjust the time and schedule for the administration of alteplase recombinant, which is a time-sensitive medication used to treat a thrombus in the coronary artery. The administration of this medication must be done within a specific time frame to be effective.Choice B rationale: This is the correct answer. Alteplase recombinant is a thrombolytic medication used to dissolve blood clots in the coronary artery. It is a time-sensitive medication, and it is crucial to administer it as soon as possible to minimize the damage to the heart muscle. Starting the medication 30 minutes earlier is an appropriate action to include in the plan of care, as it can help ensure the medication is administered within the recommended time frame.Choice C rationale: This is an inappropriate response. Alteplase recombinant should be administered within a specific time frame, typically within 3 to 4.5 hours of the onset of symptoms. Waiting up to 2 hours after the usual schedule time to give the medication would be outside the recommended time frame and could potentially reduce the effectiveness of the treatment.Choice D rationale: This is an inappropriate response. Alteplase recombinant should be infused at a specific rate, as recommended by the manufacturer or healthcare provider. Infusing the medication at a faster rate could increase the risk of adverse effects and should not be included in the plan of care without specific instructions from the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. The nurse should include that information technology will install a firewall to secure client information.
A firewall is a system that protects the network from unauthorized access and prevents data breaches. A firewall is essential for ensuring the confidentiality, integrity, and availability of electronic health records .
Choice A is wrong because the nurse should change their password more frequently than once per year. Changing passwords regularly reduces the risk of unauthorized access and enhances security .
Choice B is wrong because the documentation of sensitive material is not performed by the charge nurse. The nurse who provides the care should document it accurately and promptly in the computerized system .
Choice C is wrong because the nurse will not be given access to the medical records of every client in the facility. The nurse should only access the records of the clients they are assigned to care for, following the principle of need-to-know .
Correct Answer is A
Explanation
The correct answer is choice A, hematuria.
Hematuria is the presence of red blood cells in the urine, which can make it appear pink or cola-colored. Hematuria is a common sign of glomerulonephritis, which is inflammation of the tiny filters in the kidneys (glomeruli) that remove waste and excess fluid from the blood.
Hematuria occurs because the inflamed glomeruli allow some blood cells to leak into the urine.
Choice B, polyuria, is wrong because polyuria is the production of abnormally large amounts of urine. Polyuria is not a typical feature of acute glomerulonephritis, which may actually cause reduced urine output due to fluid retention and decreased kidney function.
Choice C, weight loss, is wrong because weight loss is not a common symptom of acute glomerulonephritis. On the contrary, weight gain may occur due to fluid retention and edema (swelling) in the face, hands, feet and abdomen.
Choice D, hypotension, is wrong because hypotension is low blood pressure. Hypotension is not usually associated with acute glomerulonephritis, which may cause high blood pressure (hypertension) due to fluid overload and impaired sodium excretion by the kidneys.
Normal ranges for blood pressure are less than 120/80 mmHg for adults.
Normal ranges for urine output are about 800 to 2000 mL per day for adults.
Normal ranges for protein in the urine are less than 150 mg per day for adults. Normal ranges for red blood cells in the urine are less than 3 per high-power field for men and less than 5 per high-power field for women.
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