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
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Related Questions
Correct Answer is D
Explanation
D. Fluid retention due to leakage of fluid leads to increase in weight
A. Capillary leak syndrome leads wet cough
B. Capillary leak syndrome leads to flushing but not bruising of the skin
C. leads to tachycardia due to reduced effective volume
Correct Answer is D
Explanation
Epoetin alfa increases red cells production and blood viscosity which can increase blood pressure leading to hypertension
A, B, C are not adverse effects of epoetin alfa
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