The nurse is administering intravenous vancomycin to a client who has had gastrointestinal surgery. Which nursing measures are appropriate? (Select all that apply.)
Restricting fluids while the client is on this medication
Administer the drug over at least 60 minutes
Reporting a trough drug level of24 mcg/mL and holding the drug
Monitoring serum creatinine levels
Instructing the client to report dizziness or a feeling of fullness in the ears
Correct Answer : B,C,D,E
A. vancomycin can be nephrotoxic and fluid restriction is inappropriate
B. Slow infusion of vancomycin is key to avoid flush reactions
C. Normal trough levels for vancomycin are 10-20mcg/ml- 24mcg/ml increases risk of toxicity
D. Monitoring serum creatinine monitors for renal damage
E. Vancomycin can cause hearing loss and clients should be advised any early signs of ototoxicity such as ear fullness
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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