Exhibits

Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

Dosage in safe range

Blood urea nitrogen 17 mg/dl. (6.07 mmol/L)

Potassium 4.4 mEq/L (4.4 mmol/L)

No known allergies

Peripheral IV in large vein

Used for prophylaxis

Answer and Explanation

Correct Answer : A,B,D,E

A.   Dosage in safe range: Ensures that the dosage of vancomycin falls within the acceptable range, minimizing the risk of toxicity.
B.   Blood urea nitrogen 17 mg/dl (6.07 mmol/L): Normal BUN levels indicate adequate renal function, which is important for the excretion of vancomycin.
C.   Potassium 4.4 mEq/L (4.4 mmol/L): While potassium levels are important for overall health, they are not directly related to the administration of vancomycin.
D.   No known allergies: Absence of allergies reduces the risk of adverse reactions to the medication.
E.   Peripheral IV in large vein: A peripheral IV in a large vein allows for the administration of vancomycin without complications such as phlebitis or infiltration.
F.   While vancomycin is being used for prophylaxis against endocarditis in this case, this alone does not indicate the safety of administering the antibiotic. Other factors such as renal function and absence of allergies are more directly related to the safety of vancomycin administration.

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Correct Answer is D

Explanation

A. Wearing gloves when interviewing the client. This behavior may make the client feel stigmatized or rejected, as it could imply that the nurse perceives them as contagious or untouchable.
B. Allowing the client to ventilate feelings. While this is important for emotional support, it does not directly address the psychosocial need for acceptance.
C. Encouraging the client to join a support group. This can help the client feel less isolated and gain support from others with similar experiences, but it is not as immediate or direct as personal interaction.
D. Shaking the client's hand during an introduction. This gesture of physical contact can significantly convey acceptance and normalcy, helping the client feel respected and accepted despite their condition.

A. Currently prescribed medications. B. Falling from a ladder as reason for admission. C. Increasing confusion of the client. D. Client's healthcare power of attorney.

Correct Answer is C

Explanation

A. Currently prescribed medications are important information, but in this emergent situation, the nurse should first report on the client's condition and immediate concerns.

B. Falling from a ladder as the reason for admission is relevant information, but it does not address the immediate clinical concern of the client's altered mental status.

C. Reporting the increasing confusion of the client is the priority as it highlights the acute change in neurological status, which may indicate a more critical issue such as intracranial injury or neurological impairment.

D. The client's healthcare power of attorney is important for long-term care planning, but it is not the immediate concern when the client presents with altered mental status and potential head
trauma.

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Exhibits Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

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Exhibits

Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.