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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:

Consulting with a pharmacist about scheduling the dose one hour after the client eats is not appropriate for risedronate. This medication should be taken on an empty stomach to ensure proper absorption. Taking it with food or beverages other than water can significantly reduce its effectiveness.

Choice B reason:

Withholding the medication until the client’s breakfast tray is available is incorrect. Risedronate should be taken first thing in the morning, at least 30 minutes before any food, drink (other than water), or other medications.

Choice C reason:

Assigning unlicensed assistive personnel (UAP) to bring the client a glass of low-fat milk is not appropriate. Milk and other beverages can interfere with the absorption of risedronate, making it less effective.

Choice D reason:

Instructing the client that it is necessary to take nothing but water with the medication is the correct action. Risedronate should be taken with a full glass of plain water to ensure it reaches the stomach quickly and is absorbed properly. This helps maximize the medication’s effectiveness and reduces the risk of esophageal irritation.

A. Photosensitivity. B. Rapid weight gain. C. Gastric irritation. D. Sexual dysfunction.

Correct Answer is B

Explanation

Choice A Reason:

Photosensitivity is not a common side effect of gabapentin. While some medications can cause increased sensitivity to sunlight, gabapentin is not typically associated with this issue. Therefore, it is not a primary concern that needs to be reported to the healthcare provider.

Choice B Reason:

Rapid weight gain is a significant side effect that should be reported to the healthcare provider. Gabapentin can cause fluid retention and swelling, which may lead to rapid weight gain. This can be a sign of more serious underlying issues, such as heart or kidney problems, and requires prompt medical attention.

Choice C Reason:

Gastric irritation, such as nausea or upset stomach, can occur with gabapentin use but is generally not severe. While it can be uncomfortable, it is usually manageable with supportive care and does not typically require immediate reporting to a healthcare provider unless it becomes severe or persistent.

Choice D Reason:

Sexual dysfunction is not commonly associated with gabapentin. While some medications can affect sexual function, gabapentin’s side effects are more commonly related to the nervous system, such as dizziness, drowsiness, and coordination issues. Therefore, this is not a primary concern that needs to be reported.

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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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Explanation

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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.