The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?
Measure oxygen saturation.
Auscultate bowel sounds.
Assess body temperature.
Check serum creatinine.
The Correct Answer is D
Measuring oxygen saturation is not directly relevant to the administration of vancomycin or the monitoring of its potential side effects. While oxygen saturation is important to assess in patients with respiratory concerns, it does not provide information about kidney function, which is essential for safe vancomycin use.
Choice B rationale:
Auscultating bowel sounds, while a part of general abdominal assessment, is not the most crucial action before administering vancomycin. Vancomycin is not known to have significant effects on bowel motility, and its primary concern is nephrotoxicity.
Choice C rationale:
Assessing body temperature can be helpful in evaluating for infection, but it is not the most specific or sensitive indicator of vancomycin-related adverse effects. Fever can be a sign of various conditions, and it does not directly assess kidney function.
Choice D rationale:
Checking serum creatinine is the most essential action before administering vancomycin because it allows for assessment of kidney function. Vancomycin is primarily excreted by the kidneys, and impaired renal function can lead to elevated drug levels and increased risk of nephrotoxicity. By checking serum creatinine, the nurse can ensure that the patient's kidney function is adequate to safely excrete vancomycin and can adjust the dosage or frequency of administration if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["38"]
Explanation
Here are the steps to calculate the IV flow rate:
Step 1: Calculate the volume to be infused per minute.
75 mL ÷ 30 minutes = 2.5 mL/minute
Step 2: Multiply the volume per minute by the drop factor to determine the drops per minute.
2.5 mL/minute × 15 gtt/mL = 37.5 gtt/minute
Step 3: Round the answer to the nearest whole number. The nurse should regulate the IV to deliver 38 gtt/minute.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Auscultating bowel sounds and measuring abdominal girth are not directly related to the management of erosive esophagitis and GERD symptoms. These actions are more pertinent to assessing gastrointestinal motility and distension, not the effectiveness of lansoprazole.
Choice B rationale: Lansoprazole is a proton pump inhibitor that should be taken before meals to reduce stomach acid production effectively. Confirming that the patient is taking the medication before meals could help optimize its efficacy but is not the most immediate step.
Choice C rationale: Notifying the healthcare provider about a potential need for a dosage change may be considered if symptoms persist. However, since healing with proton pump inhibitors can take several weeks, this action may be premature after only one week of use.
Choice D rationale: It is appropriate to inform the patient that healing of erosive esophagitis and symptom relief from GERD can take several weeks with lansoprazole. This education helps set realistic expectations and encourages adherence to the prescribed treatment.
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