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 C
Explanation
Choice A rationale
Changes to achieve low HDL and high LDL levels are not recommended. In fact, the opposite is desired. High levels of HDL (good cholesterol) and low levels of LDL (bad cholesterol) are beneficial for overall health and can help prevent cardiovascular complications associated with diabetes.
Choice B rationale
Self-monitoring of blood glucose is important for managing diabetes, but a fasting plasma glucose level of 118 mg/dL does not necessarily indicate the need for regular self-monitoring. This level is slightly elevated and may indicate prediabetes, but further testing would be needed for a definitive diagnosis.
Choice C rationale
Maintenance of a healthy weight is beneficial for everyone, but it’s particularly important for individuals with prediabetes or diabetes. Achieving and maintaining a healthy weight can help regulate blood glucose levels and prevent or delay the progression of prediabetes to diabetes.
Choice D rationale
Utilizing carbohydrate counting to match insulin intake is a strategy used in the management of diabetes. However, a fasting plasma glucose level of 118 mg/dL, while slightly elevated, does not necessarily indicate the need for insulin therapy or carbohydrate counting. Further testing would be needed to confirm a diagnosis of diabetes.
Correct Answer is C
Explanation
Wearing closed-toe shoes when walking can help protect the feet from injuries. However, it does not directly address the issue of numbness and reduced sensation due to severe peripheral neuropathy.
Choice B rationale
Soaking feet daily to remove pathogens can help maintain hygiene, but it does not directly address the issue of numbness and reduced sensation due to severe peripheral neuropathy.
Choice C rationale
Examining your feet daily is a crucial intervention for patients with severe peripheral neuropathy. Due to the numbness and reduced sensation, patients might not notice injuries or changes in their feet. Regular self-examination can help detect any abnormalities early, preventing further complications.
Choice D rationale
Using lotion on all areas of the feet for moisture can help prevent dryness and cracking of the skin, but it does not directly address the issue of numbness and reduced sensation due to severe peripheral neuropathy.
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