Exhibits

The nurse is preparing the client's plan of care.

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

Peripheral IV in large vein

No known allergies

Used for prophylaxis

Blood urea nitrogen 17 mg/dL (6.07 mmol/L)

Potassium 4.4 mEq/L (4.4 mmol/L)

Answer and Explanation

Correct Answer : A,B,C,E

A. Dosage in safe range: Ensuring that the dosage is within a safe range is crucial for preventing potential toxicity or adverse reactions.
B. Peripheral IV in large vein: Administering vancomycin through a peripheral IV in a large vein reduces the risk of phlebitis and ensures proper medication delivery.
C. No known allergies: Confirming that the client has no known allergies, especially to vancomycin or related antibiotics, is essential to avoid an allergic reaction.
D. Used for prophylaxis: While using vancomycin for prophylaxis is appropriate, this does not directly relate to safety in administration, which is more concerned with avoiding adverse reactions.
E. Blood urea nitrogen 17 mg/dL (6.07 mmol/L): A normal BUN level suggests that the kidneys are functioning properly, which is important because vancomycin is renally excreted, and impaired renal function could increase the risk of toxicity.
F. Potassium 4.4 mEq/L (4.4 mmol/L): Although within the normal range, this value does not directly impact the safety of vancomycin administration, unlike factors such as renal function or potential allergic reactions.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"C"}}

Explanation

1. Peripheral edema: Non-therapeutic side effect

- Mannitol is an osmotic diuretic that can cause fluid shifts leading to peripheral edema, which is an unintended side effect.

2. Potassium 2.9: Non-therapeutic side effect

- Hypokalemia (low potassium) is a potential side effect of mannitol due to increased urinary excretion of electrolytes.

3. Urine output 280 mL: Therapeutic result

- Mannitol increases urine output as it promotes diuresis, which is the intended therapeutic effect.

4. Heart rate 79: Unrelated finding

- The heart rate of 79 beats/minute is within normal limits and is not directly related to the administration of mannitol.

5. Intracranial pressure 11 mmHg: Therapeutic result

- The decrease in intracranial pressure from 24 mmHg to 11 mmHg is a desired therapeutic outcome of mannitol, as it helps reduce cerebral edema.

6. Oxygen saturation: Unrelated finding

- The oxygen saturation of 99% is within normal limits and is not directly related to the administration of mannitol.

A. Limit the intake of foods high in potassium. B. Cover your skin before going outside. C. Monitor skin for excessive bruising. D. Replace salt with a salt substitute.

Correct Answer is A

Explanation

A. Spironolactone is a potassium-sparing diuretic; therefore, it is important to limit potassium intake to prevent hyperkalemia.
B. Skin protection is not a specific concern related to spironolactone use.
C. Spironolactone does not commonly cause excessive bruising; monitoring for signs of hyperkalemia is more relevant.
D. Using a salt substitute may increase potassium intake, which is contraindicated with spironolactone.

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Exhibits The nurse is preparing the client's plan of care. Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions. Click to mark whether the assessment finding represents a therapeutic result of the mannitol administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"C"}}

Explanation

A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in the client's plan of care?

Correct Answer is A

Explanation

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Exhibits

The nurse is preparing the client's plan of care.

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