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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Correct Answer is D

Explanation

A. Assessing the client's strength in moving and turning is important for overall care but not specific to the need for a laxative.
B. Observing skin integrity is crucial for preventing pressure ulcers but does not directly relate to the need for a laxative.
C. Evaluating the ability to recognize the urge to defecate is important for understanding bowel habits but less relevant when preparing to administer a laxative.
D. Determining the frequency and consistency of bowel movements is essential to assess the need for a laxative and to monitor its effectiveness.

A. Increased anxiety and nervousness have been reported by those taking feverfew. B. Those with allergies to chamomile, ragweed, or yarrow should not take feverfew. C. Abdominal pain, gas, nausea, vomiting, and diarrhea can occur when taking feverfew. D. Feverfew may interact with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).

Correct Answer is B

Explanation

A. While feverfew can cause gastrointestinal issues, increased anxiety and nervousness are not commonly reported side effects.
B. Feverfew may cause allergic reactions in individuals with sensitivities to related plants like chamomile, ragweed, or yarrow, making this information crucial for preventing allergic reactions.
C. Gastrointestinal side effects like abdominal pain, gas, nausea, vomiting, and diarrhea are possible but are not as critical as the risk of an allergic reaction.
D. Interaction with aspirin or NSAIDs is a concern but is secondary to the importance of avoiding feverfew in individuals with known allergies to similar plants.

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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

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Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?

Correct Answer is D

Explanation

A client who experiences migraine headaches reports having fewer headaches since using the herbal remedy feverfew. Which information is most important for the nurse to include in a teaching plan for this client?

Correct Answer is B

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.