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.”.

None

Answer and Explanation

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.

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Correct Answer is D

Explanation

Provide humidification of the room air. This is because humidification can help moisten the oral mucosa and reduce the discomfort of xerostomia. Xerostomia is a condition of dry mouth caused by reduced or absent saliva flow, which can occur after radiation therapy to the head and neck area.

Choice A is wrong because rinsing the mouth with an alcohol-based mouth wash can irritate the oral tissues and worsen xerostomia. Alcohol can also dehydrate the mouth and reduce saliva production.

Choice B is wrong because esophageal speech is a method of voice restoration after laryngectomy, not a treatment for xerostomia.

Esophageal speech involves swallowing air into the esophagus and releasing it to create sound.

It has nothing to do with saliva flow or dry mouth.

Choice C is wrong because saltine crackers are dry and hard to swallow without adequate saliva.

They can also scratch the oral mucosa and cause pain or bleeding. Offering the client saltine crackers between meals can aggravate xerostomia and increase the risk of choking.

Normal ranges for saliva flow vary depending on the method of measurement, but generally, a stimulated saliva flow rate of less than 0.7 mL/min or an unstimulated saliva flow rate of less than 0.1 mL/min is considered indicative of xerostomia.

A. “You will be asked to change your password once per year.”. B. “Documentation of sensitive material is performed by the charge nurse.”. C. “You will be given access to the medical records of every client in the facility.”. D. “Information Technology will install a firewall to secure client information.”.

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 .

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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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?