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
Correct Answer : A,B,C,D
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): Normal potassium is important because vancomycin can cause hypokalemia; ensuring potassium is within range helps prevent complications.
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 is important for comfort and reducing vein irritation but is not a primary safety measure for determining if vancomycin can be administered.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Leaving the client alone could increase the risk of harm to herself or others and does not address the immediate need for safety and boundaries.
B: Clearly stating that undressing is unacceptable sets immediate boundaries, which is essential in managing acute behavioral situations, ensuring the client's dignity, and maintaining a professional environment.
C: Ignoring the behavior does not provide any guidance or boundaries for the client, which could lead to escalation or reinforce the inappropriate behavior.
D: While changing to less anxiety-provoking questions may be helpful, it does not directly address the behavior at hand, which could lead to further inappropriate actions or misunderstandings about acceptable behavior during the assessment.
Correct Answer is B
Explanation
A. While scheduling a client and family conference may be necessary to discuss the plan of care, the immediate concern is to determine the type of advance directive the client has and whether it includes preferences regarding resuscitation.
B. This is the most appropriate action because it addresses the family member's concern and ensures that the client's wishes regarding resuscitation are understood and followed.
C. While checking for a DNR bracelet is important, it does not address the family member's question about why the code was called despite the client having a living will.
D. This statement is incorrect. Living wills can guide decision-making regarding end-of-life care, including resuscitation, depending on the legal requirements and documentation in place.
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