The client is a 75-year-old female admitted to the preoperative area to prepare for pacemaker insertion. Client reports she is having this done because her heart rate has been staying very low, she is always tired, and she has passed out once from low heart rate. Client has history of worsening symptomatic bradycardia. History of atrial fibrillation controlled. 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

Peripheral IV in large vein

Potassium 4.4 mEq/L (4.4 mmol/L)

Used for prophylaxis

Blood urea nitrogen 17 mg/dL (6.07 mmol/L)

Dosage in safe range

Answer and Explanation

Correct Answer : A,B,D,F

A. No known allergies:
Having no known allergies is a significant factor in determining the safety of administering vancomycin, as it reduces the risk of an allergic reaction. Vancomycin can cause allergic reactions or hypersensitivity, so it’s important to ensure the client is not allergic to this medication.

B. Peripheral IV in large vein:
Vancomycin should be administered through a large vein because it can be irritating to smaller veins and potentially cause thrombophlebitis or vein damage. Using a large vein helps to minimize these risks and ensure safe administration.

C. Potassium 4.4 mEq/L (4.4 mmol/L):
While potassium levels are important to monitor, they are not directly related to the safety of administering vancomycin. Vancomycin does not have a direct impact on potassium levels, so this finding does not specifically indicate the safety of vancomycin administration.

D. Used for prophylaxis:
Vancomycin is often used as prophylaxis in certain surgical procedures to prevent infection, especially in cases where there is a high risk of methicillin-resistant Staphylococcus aureus (MRSA) infection. The use of vancomycin for prophylaxis is a common practice and indicates it is being administered for an appropriate reason.

E. Blood urea nitrogen 17 mg/dL (6.07 mmol/L):
A blood urea nitrogen (BUN) level of 17 mg/dL is slightly elevated but not necessarily a contraindication for vancomycin administration. However, vancomycin can impact kidney function, so it is important to monitor renal function but not the sole factor in determining safety.

F. Dosage in safe range:
Ensuring the dosage of vancomycin is within the safe range is crucial for preventing toxicity and achieving therapeutic efficacy. This is an essential consideration when administering the medication to avoid adverse effects and ensure effective treatment.

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Free Nursing Study Resources

Correct Answer is ["B","C","D","E"]

Explanation

A) Provide a PRN NSAID for gum pain: Administering NSAIDs is not recommended as they can exacerbate bleeding risks in clients on anticoagulants. NSAIDs can interfere with platelet function and increase bleeding tendencies.

B) Complete a medication variance report: Documenting adverse effects and any discrepancies in medication administration is crucial for patient safety and quality control. A variance report helps track and address issues related to medication effects.

C) Review most recent coagulation lab values: Evaluating recent lab results is essential to determine if the anticoagulant dosage is appropriate and if there is an increased risk of bleeding. This information guides decisions about further interventions or adjustments to the medication regimen.

D) Report findings to healthcare provider: Immediate communication with the healthcare provider is necessary to address the client’s symptoms of bleeding and bruising. The provider can then evaluate the need for treatment modification or additional measures to manage bleeding risks.

E) Obtain a soft bristle toothbrush for client: A soft bristle toothbrush helps minimize gum irritation and bleeding, which is important for clients on anticoagulants to reduce the risk of oral bleeding and maintain oral health.

A. Assess for hypoglycemia between meals. B. Provide meals at the same time this insulin is given. C. Keep an oral liquid or glucose source available. D. Check blood glucose levels every six hours.

Correct Answer is B

Explanation

A) Assess for hypoglycemia between meals: While monitoring for hypoglycemia is important, insulin lispro, being a rapid-acting insulin, primarily acts around meal times. Hypoglycemia is most likely to occur around the times when insulin lispro is active, which correlates with meal times rather than between meals.

B) Provide meals at the same time this insulin is given: Insulin lispro is a rapid-acting insulin designed to manage blood glucose levels around meal times. Administering insulin lispro immediately before or with meals helps match the insulin peak with the glucose from the meal, minimizing the risk of postprandial hyperglycemia or hypoglycemia.

C) Keep an oral liquid or glucose source available: Keeping a glucose source available is a good practice to quickly address hypoglycemia if it occurs. However, the most critical intervention is ensuring that insulin administration aligns with food intake to manage glucose levels effectively.

D) Check blood glucose levels every six hours: Checking blood glucose levels every six hours might not capture the fluctuations related to insulin lispro's rapid action. More frequent monitoring around meal times is necessary to adjust doses appropriately and prevent hyperglycemia or hypoglycemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving the third dose of a new oral anticoagulant prescription, an older adult client develops bleeding and tender gums and has many new bruises. Which actions should the nurse implement? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

Which intervention is most important for the nurse to implement for a client with type 2 diabetes mellitus (DM) who is receiving insulin lispro?

Correct Answer is B

Explanation

Which nursing intervention has priority when initiating a continuous epidural infusion with an opioid analgesic?

A client has a prescription for heparin 1,000 units IV STAT. Several pre filled syringes of low molecular weight heparin are available in the client's medication drawer. Which action should the nurse implement?

A client who is taking furosemide reports experiencing leg cramps, a cough, feeling tired, and palpitations. Which action should the nurse take first?

The nurse is caring for a client who takes methotrexate for rheumatoid arthritis and receives a prescription for adalimumab. Which instructions should the nurse provide the client?

A client receives a prescription for ciprofloxacin 400 mg intravenously (IV) every 12 hours to be infused over an hour. The IV bag contains ciprofloxacin 400 mg in dextrose 5% in water (DW) 200 mL. The nurse should program the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

The nurse is providing medication teaching to a client with bipolar disorder who receives a prescription for lithium carbonate. Which instruction should the nurse emphasize with the client?

The nurse is assessing a client who was recently diagnosed with Parkinson's disease and is taking carbidopa-levodopa. The client is concerned that the medication is not working. Which intervention should the nurse implement first?