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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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Free Nursing Study Resources

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

Explanation

Choice A: Capillary refill 2 seconds

Reason: Capillary refill time is a quick test to assess peripheral perfusion and hydration status. A normal capillary refill time is less than 2 seconds. Initially, the patient had a capillary refill time of 5 seconds, indicating poor perfusion, likely due to dehydration from vomiting and diarrhea. After the administration of IV fluids and sodium bicarbonate, the capillary refill time improved to 2 seconds, which is within the normal range. This improvement indicates that the treatment was effective in restoring adequate perfusion and hydration, making it a therapeutic result.

Choice B: Blood pressure 113/72 mm Hg

Reason: Normal blood pressure for adults is typically around 120/80 mm Hg. The patient’s initial blood pressure was 100/77 mm Hg, which is on the lower side, likely due to dehydration. After receiving IV fluids and sodium bicarbonate, the blood pressure improved to 113/72 mm Hg, which is closer to the normal range. This indicates that the treatment helped to stabilize the patient’s blood pressure, making it a therapeutic result.

Choice C: Bicarbonate 22 mEq/L (22 mmol/L)

Reason: The normal range for bicarbonate (HCO3) is 21 to 28 mEq/L. The patient’s initial bicarbonate level was 15 mEq/L, indicating metabolic acidosis, likely due to severe vomiting and diarrhea. After the administration of sodium bicarbonate, the bicarbonate level increased to 22 mEq/L, which is within the normal range. This indicates that the sodium bicarbonate effectively corrected the metabolic acidosis, making it a therapeutic result.

Choice D: Sodium 152 mEq/L (152 mmol/L)

Reason: The normal range for sodium is 135 to 145 mEq/L. The patient’s sodium level of 152 mEq/L is above the normal range, indicating hypernatremia. This could be a non-therapeutic side effect of the sodium bicarbonate administration, as sodium bicarbonate can increase sodium levels in the blood. Hypernatremia can lead to symptoms such as confusion, muscle twitching, and seizures, and requires careful monitoring and management.

Choice E: 400 mL urine output

Reason: The patient’s urine output of 400 mL is not directly related to the administration of sodium bicarbonate. Urine output is influenced by various factors, including fluid intake, kidney function, and overall hydration status. In this case, the urine output is more likely related to the patient’s overall fluid balance and hydration status rather than a direct effect of the sodium bicarbonate. Therefore, it is considered an unrelated finding.

Choice F: Heart rate 77 beats/minute

Reason: A normal resting heart rate for adults ranges from 60 to 100 beats per minute. The patient’s initial heart rate was 102 beats per minute, which is elevated, likely due to dehydration and metabolic acidosis. After receiving IV fluids and sodium bicarbonate, the heart rate decreased to 77 beats per minute, which is within the normal range. This indicates that the treatment helped to stabilize the patient’s heart rate, making it a therapeutic result.

A. Avoid taking on an empty stomach. B. Consume 2 liters of water daily. C. Reduce caffeine and acidic intake. D. Double the dose if a dose is missed.

Correct Answer is D

Explanation

Choice A Reason:

Avoiding taking allopurinol on an empty stomach is a common recommendation to prevent stomach upset. Taking the medication with food can help reduce gastrointestinal discomfort, making this advice appropriate and not requiring additional instruction.

Choice B Reason:

Consuming 2 liters of water daily is advised when taking allopurinol to help prevent kidney stones and ensure proper hydration. Adequate fluid intake helps to dilute the urine and reduce the risk of uric acid crystal formation, making this advice correct and not needing further instruction.

Choice C Reason:

Reducing caffeine and acidic intake can be beneficial for individuals taking allopurinol, as these substances can increase uric acid levels and potentially exacerbate gout symptoms. This advice is appropriate and does not require additional instruction.

Choice D Reason:

Doubling the dose if a dose is missed is incorrect and potentially dangerous. Allopurinol should be taken exactly as prescribed, and doubling up on doses can increase the risk of side effects and toxicity. If a dose is missed, the client should take it as soon as they remember, but if it is almost time for the next dose, they should skip the missed dose and continue with their regular schedule. This instruction requires correction by the nurse.

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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

Naxlex Comprehensive Predictor Exams

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

Explanation

A client receives a prescription for allopurinol. Which information provided by the client requires additional instruction by the nurse?

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.