The client has been receiving vancomycin 1 gram IV every 12 hours for 2 days.
What nursing actions are appropriate when administering this medication? (Select all that apply)

Assess for Red Man Syndrome

Assess the client’s hearing

Obtain an arterial blood gas (ABG)

Infuse the drug over 1-2 hours

Obtain an ordered trough level prior to next scheduled dose

Answer and Explanation

Correct Answer : A,B,D,E

Choice A rationale

Assess for Red Man Syndrome. Vancomycin can cause a reaction known as Red Man Syndrome, which is characterized by flushing and/or an erythematous rash that affects the face, neck, and upper torso. This is not an allergic reaction, but rather a direct histamine-release effect of the drug.

Choice B rationale

Assess the client’s hearing. Ototoxicity, which can manifest as hearing loss, is a potential side effect of vancomycin. Therefore, it’s important to monitor the client’s hearing during treatment.

Choice C rationale

Obtain an arterial blood gas (ABG). This is not typically required when administering vancomycin. ABGs are usually drawn to assess a patient’s acid-base balance and oxygenation status, not as a routine part of vancomycin administration.

Choice D rationale

Infuse the drug over 1-2 hours. Vancomycin should be administered over at least 60 minutes to avoid skin irritation. Infusing the drug too quickly can also increase the risk of Red Man Syndrome.

Choice E rationale

Obtain an ordered trough level prior to next scheduled dose. Monitoring vancomycin trough levels is important to ensure therapeutic efficacy and to avoid toxicity. Trough levels are typically drawn just before the next dose is due.

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A rationale

Soaking feet once daily in warm water is not recommended for diabetic patients. This is because prolonged soaking can lead to skin breakdown and increase the risk of foot ulcers and infections.

Choice B rationale

Utilizing a mirror to examine the soles of the feet is a recommended practice for diabetic patients. This allows them to check for any cuts, sores, blisters, or changes in the skin that they may not be able to see otherwise. Early detection of these issues can prevent serious complications such as infections and ulcers.

Choice C rationale

Cutting nails in a curved direction is not advised for diabetic patients. This can lead to ingrown toenails, which can cause sores and infections. It’s recommended to cut the nails straight across to avoid this.

Choice D rationale

Using a commercial medicine to remove a corn is not recommended for diabetic patients. These products can damage the skin and increase the risk of ulcers and infections. Any issues with corns or calluses should be addressed by a healthcare professional.

A. Administer the PRN antianxiety medication. B. Call the rapid response team. C. Increase the intravenous infusion rate. D. Prepare for mechanical ventilation.

Correct Answer is B

Explanation

Choice A rationale

Administering the PRN antianxiety medication is not the most appropriate next step. The client’s symptoms—shortness of breath, anxiety, restlessness, tachycardia, tachypnea, hypotension, and decreased oxygen saturation—are indicative of a potential pulmonary embolism, a life-threatening complication of deep vein thrombosis. While anxiety can be a symptom of a pulmonary embolism, treating it without addressing the underlying cause could delay necessary medical intervention.

Choice B rationale

Calling the rapid response team is the most appropriate next step. The client’s symptoms suggest a potential pulmonary embolism, a serious and life-threatening condition that requires immediate medical intervention. The rapid response team can provide the necessary urgent care.

Choice C rationale

Increasing the intravenous infusion rate is not the most appropriate next step. While hydration is important, it would not address the immediate life-threatening situation. The client’s symptoms suggest a potential pulmonary embolism, which requires immediate medical intervention.

Choice D rationale

Preparing for mechanical ventilation is not the most appropriate next step. While the client’s decreased oxygen saturation and increased respiratory rate suggest respiratory distress, the priority should be to address the potential pulmonary embolism. Mechanical ventilation may be necessary later depending on the client’s response to treatment.

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The client has been receiving vancomycin 1 gram IV every 12 hours for 2 days. What nursing actions are appropriate when administering this medication? (Select all that apply)

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Choice E rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse teaches a diabetic patient how to perform foot care. Which action by the patient would indicate that they can correctly perform foot care?

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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The client has been receiving vancomycin 1 gram IV every 12 hours for 2 days.
What nursing actions are appropriate when administering this medication? (Select all that apply)