Patient Data

Exhibits

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

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

No known allergies

Used for prophylaxis

Potassium 4.4 mEq/L (4.4 mmol/L)

Dosage in safe range

Peripheral IV (PIV) in large vein

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

Answer and Explanation

Correct Answer : A,D,E,F

A. No known allergies: Confirming the client has no allergies to vancomycin or related substances is critical for safe administration. Administering an antibiotic to a client with a known allergy could result in life-threatening anaphylaxis.

B. Used for prophylaxis: Although vancomycin is often used prophylactically before procedures to prevent infection, the indication alone does not ensure that it is safe to administer. Safety focuses more on client-specific factors like allergies and organ function.

C. Potassium 4.4 mEq/L (4.4 mmol/L): This is a normal potassium level and reflects good electrolyte balance but does not directly relate to the safety of administering vancomycin, which is more concerning for kidney function and allergic reactions.

D. Dosage in safe range: Verifying that the vancomycin dose is within the recommended therapeutic range is essential to prevent toxicity, particularly nephrotoxicity and ototoxicity, which are risks with improper dosing.

E. Peripheral IV (PIV) in large vein: Administering vancomycin through a large-bore IV in a large vein reduces the risk of phlebitis and tissue irritation. Proper venous access is an important safety consideration when giving this medication.

F. Blood urea nitrogen 17 mg/dL (6.07 mmol/L): A normal BUN level suggests that renal function is adequate. Since vancomycin is primarily excreted by the kidneys, good renal function supports safe medication clearance and reduces toxicity risk.

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Correct Answer is D

Explanation

A. Gingko biloba use should be limited and not taken during pregnancy: While this is true, the client in question is using it for multiple sclerosis-related symptoms and not indicated to be pregnant. This point is valid but not the most immediate safety concern for her situation.

B. Nausea and diarrhea can occur when using this supplement: These are known side effects of ginkgo biloba but are generally mild and not life-threatening. They are less critical to emphasize than potentially dangerous drug interactions.

C. Anxiety and headaches increase with the use of ginkgo: While some users may experience headaches, the occurrence of anxiety is less common. These effects are not as significant or dangerous as those involving bleeding risks when ginkgo is combined with other medications.

D. Aspirin and nonsteroidal antiinflammatory drugs (NSAID) interact with ginkgo: Ginkgo biloba has antiplatelet properties and can increase the risk of bleeding, especially when taken with aspirin or NSAIDs. This interaction is potentially serious and is the most important safety information to provide.

A. Give insulin lispro 4 units B. Restart the IV fluids until the tray arrives C. Give insulin glargine 12 units D. Mix the insulin lispro and insulin glargine in one syringe E. Verify that the client intake matches the carbohydrate count

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

Explanation

Give insulin lispro 4 units: Administering insulin lispro before the meal tray arrives is contraindicated because it can cause hypoglycemia if the client does not eat immediately. Insulin lispro should be given based on the exact carbohydrate intake, which cannot be determined until food is present.

Restart the IV fluids until the tray arrives: Restarting the IV fluids is indicated because it helps maintain hydration, especially important for a client with hyperglycemia and recent surgery. Fluids support perfusion and protect against dehydration while waiting for the client's nutritional intake to resume.

Give insulin glargine 12 units: Giving insulin glargine now is contraindicated because the client already received her scheduled dose earlier in the morning before surgery. Re-administering it could cause insulin stacking and dangerously low blood sugar later.

Mix the insulin lispro and insulin glargine in one syringe: Mixing insulin lispro and insulin glargine together is contraindicated because glargine is designed to maintain a stable, long-acting release. Mixing it can alter its absorption profile, making it unsafe to combine in the same syringe.

Verify that the client intake matches the carbohydrate count: This action is indicated because insulin lispro is prescribed to match the carbohydrate content of meals. Verifying the number of carbohydrates ensures the correct lispro dose is administered and helps prevent dosing errors and hypoglycemia.

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Patient Data Exhibits The nurse is preparing the client's plan of care (POC). 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

A female client with multiple sclerosis reports having less fatigue and improved memory since she began using the herbal supplement, ginkgo biloba. Which information is most important for the nurse to include in the teaching plan for this client?

Correct Answer is D

Explanation

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

Explanation

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Patient Data

Exhibits

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

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