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 ["A","C","D"]

Explanation

Choice A rationale:

A WBC count of 16,000/mm is higher than the normal range of 5,000 to 10,000 cells/mm. This indicates that the body is fighting an infection, which is a common reason for prescribing Vancomycin. Therefore, a high WBC count could indicate a therapeutic response to the medication as it suggests that the body’s immune system is actively fighting the infection.

Choice B rationale:

A BUN level of 42 mg/dl is higher than the normal range of 7 to 20 mg/dL3456. Elevated BUN levels can indicate kidney damage or disease, which is not a desired therapeutic response to Vancomycin. Vancomycin can be nephrotoxic, and its use requires careful monitoring of kidney function. Therefore, a high BUN level does not indicate a therapeutic response to the medication. Choice C rationale:

A blood pressure reading of 95/64 is considered normal. Maintaining normal blood pressure is important for overall health and can indicate that the patient’s body is responding well to the medication. Therefore, a blood pressure reading within the normal range could indicate a therapeutic response to Vancomycin.

Choice D rationale:

A body temperature of 101.8F is considered a fever14. Fever is a common response to infection and can indicate that the body is fighting off an infection, which is a common reason for prescribing Vancomycin. Therefore, a high body temperature could indicate a therapeutic response to the medication as it suggests that the body’s immune system is actively fighting the infection.

A. Polyuria B. Sweating C. Tachycardia D. Blurry vision

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

Explanation

Choice A rationale:

Polyuria, which is frequent or excessive urination, is not typically a symptom of hypoglycemia. It is more commonly associated with hyperglycemia, or high blood sugar levels.

Choice B rationale:

Sweating is indeed a common symptom of hypoglycemia. When blood sugar levels fall too low, the body may respond by sweating as it releases adrenaline in response to the hypoglycemic state.

Choice C rationale:

Tachycardia, or a fast heartbeat, is another common symptom of hypoglycemia. This is part of the body’s response to low blood sugar levels, as it releases adrenaline to try to raise these levels.

Choice D rationale:

Blurry vision can be a symptom of hypoglycemia. When blood sugar levels fall, it can affect the ability of the eyes to focus, leading to blurry vision.

Choice E rationale:

Polydipsia, or excessive thirst, is not typically a symptom of hypoglycemia. Like polyuria, it is more commonly associated with hyperglycemia.

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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

Examine the following patient data for a patient who has been prescribed vancomycin. The nurse is evaluating a patient after administering several doses of Vancomycin IV. Which of the following changes would indicate a therapeutic response to the medication? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply.)

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

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?

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