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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.

No known allergies

Dosage in safe range

Potassium 4.4 mEq/L (4.4 mmol/L)

Peripheral IV in large vein

Used for prophylaxis

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

Answer and Explanation

Correct Answer : A,B,D,E

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.

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Correct Answer is D

Explanation

Choice A Reason:

Antiretroviral medications are effective in decreasing AIDS-related complications. These medications work by reducing the viral load in the body, which helps to maintain the immune system and prevent the progression of HIV to AIDS. By keeping the viral load low, the risk of opportunistic infections and other complications associated with AIDS is significantly reduced.

Choice B Reason:

One of the primary goals of antiretroviral therapy (ART) is to decrease the viral load to an undetectable level. When the viral load is undetectable, it means that the amount of HIV in the blood is so low that it cannot be detected by standard laboratory tests. Achieving and maintaining an undetectable viral load is crucial for the health of the individual and helps to prevent the progression of the disease.

Choice C Reason:

It is important to understand that while antiretroviral therapy can control HIV infection and reduce the viral load to undetectable levels, it does not cure the infection. HIV remains in the body, and if the medication is stopped, the viral load will increase again. Continuous adherence to the medication regimen is necessary to keep the virus under control and maintain health.

Choice D Reason:

While antiretroviral therapy significantly reduces the risk of HIV transmission, it does not completely prevent it. The concept of “undetectable = untransmittable” (U=U) means that individuals with an undetectable viral load have effectively no risk of transmitting the virus through sex7. However, it is still important to use other preventive measures, such as condoms, to further reduce the risk of transmission.

A. Use relaxation techniques to reduce excessive anxiety. B. Avoid alcohol and other sedatives while taking the medication. C. Move slowly from a sitting position to a standing position. D. Stop taking the medication if intended effect is not immediate.

Correct Answer is D

Explanation

The correct answer is d. Stop taking the medication if intended effect is not immediate.

Choice A Reason:

Using relaxation techniques to reduce excessive anxiety is a beneficial practice for managing generalized anxiety disorder (GAD). Techniques such as deep breathing, meditation, and progressive muscle relaxation can complement medication therapy and help reduce anxiety symptoms1. This statement does not require additional instruction as it aligns with recommended practices.

Choice B Reason:

Avoiding alcohol and other sedatives while taking lorazepam is crucial. Lorazepam is a benzodiazepine that can cause sedation and depress the central nervous system. Combining it with alcohol or other sedatives can enhance these effects, leading to dangerous levels of sedation, respiratory depression, or even overdose2. This advice is appropriate and does not need further instruction.

Choice C Reason:

Moving slowly from a sitting position to a standing position is important to prevent dizziness or lightheadedness, which can be side effects of lorazepam3. This precaution helps reduce the risk of falls and injuries, making it a suitable recommendation that does not require additional instruction.

Choice D Reason:

Stopping the medication if the intended effect is not immediate requires additional instruction. Lorazepam, like other benzodiazepines, may not produce immediate effects, especially in the context of anxiety management. It is important for clients to understand that medication may take some time to achieve the desired therapeutic effect and that abrupt discontinuation can lead to withdrawal symptoms and a potential rebound in anxiety4. The nurse should instruct the client to follow the prescribed regimen and consult their healthcare provider before making any changes to their medication.

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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.

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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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.