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

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is Choice D.

Let’s go through the calculations step by step:

Step 1: Convert all the quantities to milliliters (mL), as the nurse needs to record the intake in mL. We know that 1 oz is approximately 29.5735 mL.

4 oz of juice = 4 × 29.5735 mL = 118.294 mL

6 oz of tea = 6 × 29.5735 mL = 177.861 mL 8 oz of broth = 8 × 29.5735 mL = 236.628 mL Step 2: Add all the quantities together:

118.294 mL (juice) + 177.861 mL (tea) + 100 mL (soda) + 150 mL (IV bolus) + 236.628 mL (broth) = 783.783 mL Step 3: Round off the total intake to the nearest whole number as required, which gives us 784 mL.

Therefore, the nurse should record 784 mL on the patient’s chart. However, this option is not available in the choices given. The closest option to this calculated value is 800 mL (Choice D).

Now, let’s discuss the rationales for each choice:

Choice A rationale:

500 mL would be an underestimate of the patient’s fluid intake. It does not account for all the fluids the patient consumed.

Choice B rationale:

600 mL, similar to Choice A, is an underestimate. It does not accurately represent the total volume of fluids the patient consumed. Choice C rationale:

700 mL is closer to the calculated intake but is still an underestimate. It does not fully account for all the fluids the patient consumed.

Choice D rationale:

800 mL is the closest option to the calculated intake of 784 mL. Although it’s slightly over the actual intake, it’s the best choice among the given options.

A. “I will feel shaky.” B. “My skin will be warm and moist.” C. “I will be more thirsty than usual.” D. “My appetite will be decreased.”

Correct Answer is A

Explanation

Choice A rationale:

Hypoglycemia, also known as low blood sugar, is a condition where blood sugar levels fall below the standard range. It is often related to diabetes treatment. When blood glucose levels are too low, individuals may experience symptoms such as shakiness, which is why the statement “I will feel shaky” indicates an understanding of the manifestations of hypoglycemia.

Choice B rationale:

The statement “My skin will be warm and moist” does not accurately represent the symptoms of hypoglycemia. While sweating can be a symptom of hypoglycemia, it does not necessarily mean that the skin will feel warm and moist. Therefore, this choice does not indicate a correct understanding of the manifestations of hypoglycemia.

Choice C rationale:

The statement “I will be more thirsty than usual” is more commonly associated with hyperglycemia, or high blood sugar, rather than hypoglycemia. Thirst is not typically a symptom of low blood sugar. Therefore, this choice does not indicate a correct understanding of the manifestations of hypoglycemia.

Choice D rationale:

The statement “My appetite will be decreased” is not a typical symptom of hypoglycemia. In fact, hunger is a common symptom of low blood sugar. Therefore, this choice does not indicate a correct understanding of the manifestations of hypoglycemia.

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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)

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Naxlex Comprehensive Predictor Exams

A nurse is documenting an 8-hour intake and output (I&O) record for a patient who consumed 4 oz of juice, 6 oz of tea, a 100 mL cup of soda, an IV bolus of 150 mL, and 8 oz of broth. How many mL of intake should the nurse record on the patient’s chart?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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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)