Examine the following patient data for a patient who has been prescribed vancomycin.
The nurse is evaluating a patient after administering several doses of Vancomycin IV. Which of the following changes would indicate a therapeutic response to the medication? (Select all that apply)
WBC count of 16,000/mm
BUN level of 42 mg/dl
Blood pressure reading of 95/64
Body temperature of 101.8F
Correct Answer : A,C,D
Choice A rationale:
A WBC count of 16,000/mm is higher than the normal range of 5,000 to 10,000 cells/mm. This indicates that the body is fighting an infection, which is a common reason for prescribing Vancomycin. Therefore, a high WBC count could indicate a therapeutic response to the medication as it suggests that the body’s immune system is actively fighting the infection.
Choice B rationale:
A BUN level of 42 mg/dl is higher than the normal range of 7 to 20 mg/dL3456. Elevated BUN levels can indicate kidney damage or disease, which is not a desired therapeutic response to Vancomycin. Vancomycin can be nephrotoxic, and its use requires careful monitoring of kidney function. Therefore, a high BUN level does not indicate a therapeutic response to the medication. Choice C rationale:
A blood pressure reading of 95/64 is considered normal. Maintaining normal blood pressure is important for overall health and can indicate that the patient’s body is responding well to the medication. Therefore, a blood pressure reading within the normal range could indicate a therapeutic response to Vancomycin.
Choice D rationale:
A body temperature of 101.8F is considered a fever14. Fever is a common response to infection and can indicate that the body is fighting off an infection, which is a common reason for prescribing Vancomycin. Therefore, a high body temperature could indicate a therapeutic response to the medication as it suggests that the body’s immune system is actively fighting the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Shaking the insulin vial vigorously is not recommended. It can lead to the formation of bubbles, which can affect the accuracy of the dose. Instead, insulin vials should be gently rolled between the hands to mix.
Choice B rationale:
Injecting insulin into the abdominal area is indeed a recommended practice. The abdomen is a preferred site for insulin injection because it has a faster absorption rate compared to other areas. This can help to more effectively regulate blood glucose levels.
Choice C rationale:
Exercise typically lowers blood glucose levels, so insulin doses may need to be reduced to prevent hypoglycemia. Clients should monitor their blood glucose closely and adjust insulin as directed by their healthcare provider.
Choice D rationale:
Freezing unopened insulin vials is not advised. Freezing can disrupt the insulin structure, rendering it ineffective. Insulin should be stored in a refrigerator at a temperature between 2°C and 8°C (36°F and 46°F). Once opened, it can be kept at room temperature for up to 28 days.
Correct Answer is ["2.5 "]
Explanation
Step 1: Identify the given values. The nurse needs to administer 2.5 mg of hydromorphone. The available amount is 5 mg/5 mL.
Step 2: Set up the calculation. We need to find out how many mL correspond to 2.5 mg. We can set up a proportion using the given values:
5 mL5 mg=x mL2.5 mg
Step 3: Solve for x. Cross-multiply and solve for x:
5 mg×x mL=2.5 mg×5 mL
Step 4: Simplify the equation:
x=5 mg.5 mg×5 mL
Step 5: Calculate the value of x:
x=2.5 mL
So, the nurse should administer 2.5 mL of the hydromorphone elixir.
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