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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The hemoglobin A1C test, also known as the HbA1C or glycated hemoglobin test, is a blood test that evaluates glycemic control over a 3-month period by measuring the glucose attached to hemoglobin. This test is commonly used to diagnose and monitor diabetes. It provides an average of your blood sugar levels over the past 2-3 months, which can help healthcare providers assess how well diabetes is being managed.
Choice B rationale
The hemoglobin A1C test does not use the level of serum protein to evaluate glycemic control. Instead, it measures the amount of glucose that is attached to the hemoglobin in your red blood cells.
Choice C rationale
The hemoglobin A1C test does not evaluate serum ketone production over several days. Ketones are produced when the body burns fat for energy, which can occur when there is not enough insulin to help your body use sugar for energy. High levels of ketones can lead to diabetic ketoacidosis, a serious condition that requires immediate medical attention.
Choice D rationale
The hemoglobin A1C test does not determine the amount of glucose attached to hemoglobin over the last seven days. Instead, it provides an average of your blood sugar levels over the past 2-3 months. -
Correct Answer is C
Explanation
A heart murmur due to mitral valve disease is typically heard loudest over the mitral area, which is located at the fifth intercostal space in the left midclavicular line.
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