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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A serum fasting glucose of 101 mg/dL is slightly above the normal range (70-100 mg/dL), indicating a possible prediabetes condition. However, it is not a contraindication for trimethoprim-sulfamethoxazole.
Choice B rationale
A platelet count of 160,000 uL is within the normal range (150,000-450,000 uL). Therefore, it is not a contraindication for trimethoprim-sulfamethoxazole.
Choice C rationale
A hemoglobin level of 13.6 g/dL is within the normal range for both men (13.5-17.5 g/dL) and women (12.0-15.5 g/dL). Thus, it is not a contraindication for trimethoprim-sulfamethoxazole.
Choice D rationale
A serum creatinine level of 2.5 mg/dL is above the normal range (0.6-1.2 mg/dL for men, 0.5- 1.1 mg/dL for women), indicating impaired kidney function. Trimethoprim-sulfamethoxazole is contraindicated in patients with severe renal insufficiency.
Correct Answer is C
Explanation
Choice A rationale
Placing the patient back on the heparin infusion and redrawing laboratory values would not be the appropriate next step. The INR of 1.9 is below the therapeutic range of 2.0 - 3.0 for most patients on warfarin. Therefore, the warfarin therapy is not yet fully effective, and there is no need to revert to heparin.
Choice B rationale
Asking the healthcare provider if the patient’s medication can be changed to rivaroxaban would not be the appropriate next step. Rivaroxaban is a different type of anticoagulant and would not necessarily be more effective in this situation.
Choice C rationale
Notifying the healthcare provider and asking if the dose of warfarin can be increased would be the appropriate next step. The INR of 1.9 is below the therapeutic range of 2.0 - 3.0 for most patients on warfarin. Therefore, an increase in the warfarin dose may be necessary to achieve therapeutic anticoagulation.
Choice D rationale
Preparing to administer a dose of Vitamin K subcutaneously would not be the appropriate next step. Vitamin K is used to reverse the effects of warfarin and would be counterproductive in this situation.
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