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 D

Explanation

Choice A rationale:

Insulin is not absorbed most rapidly when injected in the thigh. The abdomen is actually the preferred site for insulin injection as insulin is absorbed more quickly and predictably there. The thigh is a simple area for self-injection, but regular injections in the thigh can sometimes cause discomfort when walking or running afterward.

Choice B rationale:

Using cold insulin for injection to minimize site pain is not recommended. Insulin should be at room temperature. Cold insulin might make the injection more painful.

Choice C rationale:

Massaging the site after injection to promote absorption is not advised. It can cause the insulin to be absorbed too quickly which can lead to low blood glucose levels.

Choice D rationale:

Rotating the injection site to keep insulin levels consistent is the correct choice. People who take insulin daily should rotate their injection sites. This is important because using the same spot over time can cause lipodystrophy. In this condition, fat either breaks down or builds up under the skin, causing lumps or indentations that interfere with insulin absorption.

A. The client refuses breakfast and requests to sleep. B. The client asks the AP to trim his broken toenail. C. The client reports urine that is dark yellow in color. D. The client reports dizziness when standing.

Correct Answer is A

Explanation

Choice A rationale:

Type 1 diabetes mellitus is a chronic medical condition that occurs when the pancreas, an organ in the abdomen, produces very little or no insulin. Insulin is a hormone that helps the body to use glucose for energy. Glucose is a sugar that comes, in large part, from foods we eat. Insulin allows glucose to enter cells in the body. Therefore, if a client with type 1 diabetes refuses breakfast and requests to sleep, it could lead to hypoglycemia, a condition characterized by abnormally low blood glucose levels. Hypoglycemia can cause symptoms such as weakness, sweating, confusion, and in severe cases, unconsciousness or seizures. It is a medical emergency and should be reported immediately.

Choice B rationale:

Trimming a toenail may seem like a simple task, but for a person with diabetes, it can lead to serious complications. Diabetes can cause nerve damage that leads to numbness in the feet, making it difficult for a person to feel a cut, blister, or sore. These injuries can become infected and lead to serious complications, such as the need for amputation. However, this situation is not as immediately life-threatening as hypoglycemia and does not need to be reported immediately.

Choice C rationale:

Dark yellow urine can be a sign of dehydration, which can be a concern for individuals with diabetes. However, it can also be a result of less serious causes such as certain medications, foods, or simply not drinking enough fluids. While it’s important for the AP to encourage the client to drink more fluids, this situation is not as immediately life-threatening as hypoglycemia.

Choice D rationale:

Dizziness when standing, also known as orthostatic hypotension, can be a side effect of some medications used to treat diabetes. It can also be a symptom of dehydration or other conditions. While it’s important for the AP to monitor the client’s symptoms and report any changes, this situation is not as immediately life-threatening as hypoglycemia

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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 reinforcing teaching about insulin injections with a client who is newly diagnosed with type I diabetes mellitus. Which of the following information should the nurse include about site selection?

Correct Answer is D

Explanation

A nurse is discussing the care of a client who has type 1 diabetes mellitus with an assistive personnel (AP). Which of the following situations should the nurse instruct the AP to report immediately?

Correct Answer is A

Explanation

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.

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