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

Answer and Explanation

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

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Correct Answer is D

Explanation

D. Vancomycin is an ototoxic antibiotic
A. Vancomycin is nephrotoxic and restricting fluid intake increases the risk of renal damage
B. Vancomycin does not cause change in urine color
C. The client should take the medication as prescribed regardless of symptoms for clearance of infection

A. Do nothing B. Report the bleb to the physician. C. Massage the area D. Apply heat

Correct Answer is A

Explanation

A. It is expected and should be observed for reaction

B. Reporting is not necessary as it is expected
C,D. Massaging the area or applying heat interferes with the test results.

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The nurse is administering intravenous vancomycin to a client who has had gastrointestinal surgery. Which nursing measures are appropriate? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about Vancomycin with a client who has an infection. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

After administering an intradermal (ID) injection for a skin test, the nurse notices a small bleb at the injection site. Which of these is the best action for the nurse to take at this time?

Correct Answer is A

Explanation

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