A patient is receiving vancomycin. Which physiological function is the priority for the nurse to assess?
Vision
Heart tones
Bowel sounds
Hearing
The Correct Answer is D
A. Vision is not commonly affected by vancomycin, so it is not a priority to assess.
B. Heart tones are not directly impacted by vancomycin and do not require immediate monitoring unless there are specific cardiovascular concerns.
C. Bowel sounds are not directly influenced by vancomycin and do not need to be prioritized in this case.
D. Vancomycin is known to be ototoxic, especially in high doses or with prolonged use, so monitoring for signs of hearing loss or tinnitus is essential to prevent potential irreversible damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The pharmacist is responsible for filling prescriptions accurately but does not have control over how the nurse interprets the prescription once received.
B. The nurse has the ultimate responsibility for verifying and administering medications safely, including clarifying unclear prescriptions before administration.
C. The hospital has policies and systems in place to reduce errors, but accountability for individual actions lies with the nurse administering the medication.
D. The health care provider is responsible for prescribing medications accurately; however, the nurse must confirm and clarify any unclear prescriptions before administration.
Correct Answer is C
Explanation
A. Identifying immobility hazards requires clinical judgment and assessment skills that are beyond the scope of nursing assistive personnel.
B. Determining the level of comfort is a subjective assessment that should be done by a nurse to ensure accurate interpretation of the patient’s condition.
C. Changing the patient's position can be safely delegated to nursing assistive personnel, as it is a straightforward task that does not require advanced clinical judgment.
D. Assessing circulation involves evaluating the patient's vital signs and other parameters, which should be performed by a nurse to ensure comprehensive care and assessment.
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