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Patient Data

Exhibits

The nurse is evaluating the client’s progress and nursing implementations. Bold the words to highlight the findings that would indicate the client has recovered from the adverse drug reaction.

1230: Shaking is lessened. Client is no longer flushed. No longer itching. Anxiety has decreased. Skin warm and dry. Heart rate 62 beats/minute, blood pressure 130/72 mm Hg. No chest pain noted. Respirations are even and unlabored. Drowsy.

Shaking is lessened.

Client is no longer flushed.

No longer itching.

Anxiety has decreased.

Skin warm and dry.

Heart rate 62 beats/minute, blood pressure 130/72 mm Hg.

No chest pain noted

Respirations are even and unlabored

Drowsy

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G","H"]

Choice A reason:

Shaking is lessened: This indicates that the client’s nervous system is stabilizing. Shaking or tremors can be a sign of an adverse drug reaction, particularly if the reaction involves the central nervous system. The lessening of shaking suggests that the adverse effects are subsiding and the client’s condition is improving.

Choice B reason:

Client is no longer flushed: Flushing is a common symptom of an adverse drug reaction, particularly with medications like vancomycin, which can cause “red man syndrome.” The absence of flushing indicates that the reaction is resolving and the client’s skin is returning to its normal state.

Choice C reason:

No longer itching: Itching is a common symptom of an allergic reaction. The cessation of itching suggests that the histamine response is diminishing, indicating that the adverse reaction is being controlled and the client is recovering.

Choice D reason:

Anxiety has decreased: Anxiety can be a symptom of an adverse drug reaction, particularly if the reaction involves the cardiovascular or nervous system. The decrease in anxiety indicates that the client’s overall condition is stabilizing and that the adverse effects are subsiding.

Choice E reason:

Skin warm and dry: Normal skin temperature and moisture levels indicate that the client’s autonomic nervous system is functioning properly. This is a positive sign that the adverse drug reaction is resolving and the client’s body is returning to its normal state.

Choice F reason:

Heart rate 62 beats/minute, blood pressure 130/72 mm Hg: These vital signs are within normal ranges for a resting adult. A normal heart rate (60-100 beats per minute) and blood pressure (less than 120/80 mm Hg) indicate that the client’s cardiovascular system is stabilizing and that the adverse drug reaction is resolving.

Choice G reason:

No chest pain noted: The absence of chest pain is a positive sign, as chest pain can be a symptom of a severe adverse drug reaction, particularly if it involves the cardiovascular system. The lack of chest pain indicates that the client’s condition is improving.

Choice H reason:

Respirations are even and unlabored: Normal respiratory function indicates that the client’s respiratory system is not being adversely affected by the drug reaction. Even and unlabored respirations suggest that the client is recovering and that the adverse effects are subsiding.

Choice I reason:

Drowsy: While drowsiness can be a side effect of medications like diphenhydramine, it can also indicate that the client’s body is relaxing and recovering from the adverse drug reaction. Drowsiness in this context is a sign that the client is stabilizing and that the adverse effects are being managed.

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Correct Answer is ["A","B","D","E"]

Explanation

Choice A: No known allergies

Reason: The absence of known allergies is crucial when administering any medication, including antibiotics like vancomycin. Allergic reactions to antibiotics can range from mild rashes to severe anaphylaxis, which can be life-threatening. In this case, the patient has reported no known allergies, which significantly reduces the risk of an adverse reaction to vancomycin. This makes it safer to proceed with the administration of the antibiotic. Ensuring that the patient has no known allergies is a standard precaution in medical practice to prevent potential allergic reactions.

Choice B: Dosage in safe range

Reason: The dosage of vancomycin must be within a safe range to avoid toxicity. Vancomycin is typically dosed based on the patient’s weight and renal function. For adults, the usual dose is 15-20 mg/kg, administered every 8-12 hours, depending on the severity of the infection and the patient’s renal function. In this scenario, the prescribed dose is 1 gram in 250 mL of 0.9% sodium chloride, which is within the safe range for an adult patient. Administering the correct dosage is essential to ensure the effectiveness of the antibiotic while minimizing the risk of nephrotoxicity and ototoxicity, which are potential side effects of vancomycin.

Choice C: Potassium 4.4 mEq/L (4.4 mmol/L)

Reason: While the potassium level of 4.4 mEq/L is within the normal range (3.5-5.0 mEq/L), it is not directly related to the safety of administering vancomycin. Potassium levels are more relevant to the overall electrolyte balance and cardiac function but do not specifically impact the administration of vancomycin. Therefore, this choice is not as pertinent to the safety of vancomycin administration as the other options.

Choice D: Peripheral IV in large vein

Reason: Administering vancomycin through a peripheral IV in a large vein is important to reduce the risk of phlebitis and irritation. Vancomycin is known to be irritating to veins, and using a large vein helps to dilute the medication more effectively, reducing the risk of vein inflammation. In this case, the peripheral IV was started in the right antecubital with a 20-gauge catheter, which is appropriate for the administration of vancomycin. Ensuring proper IV placement and using a large vein can help prevent complications associated with IV administration of this antibiotic.

Choice E: Used for prophylaxis

Reason: Vancomycin is being used as a prophylactic measure to prevent endocarditis in this patient. Prophylactic use of antibiotics is common in patients undergoing certain surgical procedures, especially those with a history of heart conditions, to prevent bacterial infections. In this case, the patient is undergoing pacemaker insertion, and the use of vancomycin as prophylaxis is appropriate to prevent potential infections. Prophylactic administration of antibiotics like vancomycin is a standard practice to reduce the risk of postoperative infections, particularly in patients with a higher risk of complications.

Choice F: Blood urea nitrogen 17 mg/dl (6.07 mmol/L)

Reason: The blood urea nitrogen (BUN) level of 17 mg/dL is within the normal range (7-20 mg/dL). While BUN levels are important indicators of renal function, they are not directly related to the safety of administering vancomycin in this context. Vancomycin dosing does need to consider renal function, but the BUN level alone does not provide sufficient information to determine the safety of administration. Therefore, this choice is not as directly relevant as the other options.

A. Are you taking any supplements? B. Have you experienced itching or hives? C. Have you noticed that your skin is dry? D. Have you noticed the need to urinate less often? E. Do you use any salt substitutes? F. Have you experienced urgency to urinate?

Correct Answer is ["A"]

Explanation

Choice A reason:

Asking if the client is taking any supplements is important because certain supplements can affect blood urea nitrogen (BUN) levels. For example, high protein supplements can increase BUN levels, while others might interact with medications or affect kidney function.

Choice B reason:

Inquiring about itching or hives is relevant for identifying potential allergic reactions or side effects from medications or supplements. However, it is not directly related to the BUN levels.

Choice C reason:

Dry skin can be a symptom of various conditions, including dehydration or kidney issues. While it is a useful question, it does not directly address the BUN levels.

Choice D reason:

Asking if the client has noticed the need to urinate less often is crucial for assessing kidney function. Reduced urine output can indicate kidney dysfunction, which can affect BUN levels.

Choice E reason:

Using salt substitutes is relevant because some contain potassium, which can affect kidney function and electrolyte balance. This question helps assess potential dietary influences on BUN levels.

Choice F reason:

Experiencing urgency to urinate can be a symptom of urinary tract issues or other conditions. While it is important to know, it is not directly related to the BUN levels.

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Naxlex Comprehensive Predictor Exams

Patient Data 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.

Correct Answer is ["A","B","D","E"]

Explanation

The nurse reviews the laboratory values. What question(s) can the nurse ask the client based on the laboratory results? Select all that apply.

Correct Answer is ["A"]

Explanation

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