The nurse checks the patient’s laboratory work prior to administering a dose of vancomycin and finds that the trough vancomycin level is 24 mcg/mL. What will the nurse do next?

Hold the drug, and administer 4 hours later.

Administer the vancomycin as ordered.

Hold the drug, and notify the prescriber.

Repeat the test to verify results.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Holding the drug and administering it 4 hours later is not the appropriate action. The trough vancomycin level of 24 mcg/mL is higher than the recommended range of 10-20 mcg/mL, indicating potential risk for toxicity. Administering the drug later does not address the immediate concern of a high trough level.

Choice B rationale:

Administering the vancomycin as ordered is not the correct action in this case. The trough level is above the recommended range, which could lead to vancomycin toxicity. The nurse should not administer the medication without addressing the high trough level. Choice C rationale:

This is the correct action. The nurse should hold the drug and notify the prescriber because the trough vancomycin level is higher than the recommended range. The prescriber can then make a decision based on this information, which may include adjusting the dose, extending the dosing interval, or ordering additional tests.

Choice D rationale:

While repeating the test to verify results might be done eventually, it should not be the immediate next step. The nurse has a responsibility to ensure patient safety, and with a trough level above the recommended range, the priority is to prevent potential toxicity. Therefore, the nurse should hold the drug and notify the prescriber.

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Correct Answer is ["0.6 "]

Explanation

Answer and explanation

The question is about calculating the volume of methylnaltrexone to administer to a client. The client needs a dose of 12 mg, and the available methylnaltrexone is 8 mg/0.4 mL.

Let’s calculate the volume step by step:

Step 1: Identify the given values:

Desired dose (D) = 12 mg
Available dose (A) = 8 mg
Volume for available dose (V) = 0.4 mL

Step 2: Use the given values in the formula for calculating the volume to administer:

Volume to administer=Available doseDesired dose×Volume for available dose Step 3: Substitute the given values into the formula:

Volume to administer=(12*0.4)/8

Step 4: Perform the multiplication and division:

Volume to administer=4.8mL/8

Step 5: Simplify the division to find the volume to administer:

Volume to administer=0.6mL

So, the nurse should administer 0.6 mL of methylnaltrexone to the client.

A. It’s best to wait to see if the fever gets worse. B. You can use the aspirin, but watch for worsening symptoms. C. Acetaminophen should be used to reduce his fever, not aspirin. D. You can use aspirin but be sure to follow the instructions on the bottle.

Correct Answer is C

Explanation

Choice A rationale:

Waiting to see if the fever gets worse is not the best course of action. Fever is a symptom that the body is fighting off an infection, and it can cause discomfort in children. However, the main concern with chickenpox and fever is not the fever itself, but the risk of complications from the chickenpox. Therefore, it’s important to manage the fever for the child’s comfort but also monitor for any signs of complications.

Choice B rationale:

Aspirin should not be given to children or teenagers who have chickenpox or flu symptoms before a doctor is consulted about Reye’s Syndrome, a rare but serious illness. Reye’s syndrome is a potentially life-threatening condition that has been associated with aspirin use in children and adolescents with viral illnesses, especially chickenpox or influenza.

Choice C rationale:

Acetaminophen (Tylenol) should be used to reduce his fever, not aspirin. This is because of the risk of Reye’s syndrome associated with aspirin use in children and adolescents who have viral illnesses. Acetaminophen is a safe and effective choice for fever reduction in children.

Choice D rationale:

While it’s important to always follow the instructions on the bottle when giving medication, aspirin should not be used in children or teenagers with chickenpox due to the risk of Reye’s syndrome. Therefore, this advice could potentially lead to a dangerous situation.

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The nurse checks the patient’s laboratory work prior to administering a dose of vancomycin and finds that the trough vancomycin level is 24 mcg/mL. What will the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer methylnaltrexone 12 mg subcutaneously to a client who has opioid-induced constipation. The available methylnaltrexone is 8 mg/0.4 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies.

Correct Answer is ["0.6 "]

Explanation

A 6-year-old child who has chickenpox also has a fever of 102.9 F (39.4 C). The child’s mother asks the nurse if she should use aspirin to reduce the fever. What is the best response by the nurse?

Correct Answer is C

Explanation

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The nurse checks the patient’s laboratory work prior to administering a dose of vancomycin and finds that the trough vancomycin level is 24 mcg/mL. What will the nurse do next?