The nurse observes an unlicensed assistive personnel (UAP) preparing to provide personal care for a patient who requires contact precautions. The UAP has put on a gown and gloves and has secured the tops of the gloves over the gown sleeves. What action should the nurse take?

Choice A rationale
A potassium level of 4.4 mEq/L (4.4 mmol/L) is within the normal range. Potassium is a critical electrolyte in the body, playing key roles in cellular metabolism, protein synthesis, and electrical action potential regulation across cell membranes. Normal potassium levels typically range from 3.5 to 5.1 mmol/L1. Therefore, a potassium level of 4.4 mEq/L indicates that the patient’s potassium level is within the normal range, which is a safe condition for the administration of vancomycin.
Choice B rationale

The use of antibiotics for prophylaxis, or prevention, is a common practice in healthcare, particularly in surgical procedures such as pacemaker insertion. This is done to prevent potential infections that could occur during or after the procedure. Vancomycin is a type of antibiotic that is often used for prophylaxis against infections caused by gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA)3. Therefore, if the antibiotic is being used for prophylaxis, it would be safe to administer vancomycin.
Choice C rationale
A blood urea nitrogen (BUN) level of 17 mg/dL (6.07 mmol/L) is within the normal range. The BUN test measures the amount of urea nitrogen in the blood, which can provide important information about kidney function. Urea nitrogen is a waste product that is created in the liver when protein is metabolized. It is then transported through the blood to the kidneys, which filter out most of the urea nitrogen, leaving a small amount in the blood. Normal BUN levels typically range from 6 to 20 mg/dL4. Therefore, a BUN level of 17 mg/dL indicates that the patient’s kidney function is within the normal range, which is a safe condition for the administration of vancomycin.
Choice E rationale
The absence of known allergies in a patient is a crucial factor in determining the safety of administering any medication, including vancomycin. Allergic reactions to medications can range from mild symptoms such as rash and itching to severe and life-threatening conditions such as anaphylaxis. Therefore, if a patient has no known allergies, it would be safe to administer vancomycin.
Choice D rationale

While it’s true that the dosage of the antibiotic should be within the safe range, the specific dosage of vancomycin for the patient isn’t provided in the question. Therefore, we cannot definitively say that this condition is met based on the information given.
Choice F rationale
Although vancomycin can be administered via a peripheral IV in a large vein, it’s important to note that vancomycin has a low pH and may cause venous irritation and tissue damage in cases of extravasation. Therefore, while it’s possible to administer vancomycin this way, it’s not necessarily an indicator of safety.

Choice A rationale
Ceasing the use of the nasal cannula would interrupt the client’s oxygen therapy, which could potentially worsen their condition. Therefore, this is not the best course of action.
Choice B rationale
Reducing the flow rate to 1 L/minute may not be appropriate as the client’s oxygen needs may not be met at a lower flow rate. The redness under the chin is likely due to the friction from the cannula tubing, not the flow rate of the oxygen.
Choice C rationale
Applying lubricant to the cannula tubing may not be effective in preventing skin breakdown and could potentially cause additional discomfort or complications for the client.
Choice D rationale
Attaching padding around the cannula tubing can help reduce the friction between the tubing and the skin, which can help prevent skin breakdown. This is the most appropriate action to take in this situation.