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Thirty minutes into the administration of the IV dose and 30 minutes before the next administration of the medication: This timing doesn't align with the standard practice of drawing peak levels immediately after the IV dose is completed.The trough level should be taken just before the next dose, not 30 minutes before.

Two hours after completion of the IV dose and 1 hour before the next administration of the medication:Waiting for two hours after the dose to draw the peak level is too long. Peak levels are typically drawn immediately after completion.Drawing the trough level one hour before the next dose doesn't provide an accurate assessment of the lowest drug concentration just before the next administration.

One hour after completion of the IV dose and one hour before the next administration of the medication:
Similar to choice B, waiting one hour after the dose to draw the peak level is not in line with standard practice.Drawing the trough level one hour before the next dose is administered is too early to accurately represent the lowest concentration.The best collection times for determining the peak and trough levels of intravenous (IV) vancomycin are:

While administering a stool softener or laxative can be important to prevent constipation associated with opioids, it is not the highest priority action at the time of medication administration. Ensuring the client's safety during ambulation takes precedence.
The nursing action with the highest priority when administering a dose of codeine with acetaminophen to a client is:

Tell the client to notify the nurse if the pain is not relieved:This is an important instruction, but it is not the highest priority when the client is about to ambulate. Safety during ambulation is the immediate concern.

Advise the client that the medication should start to work in about 30 minutes:Providing information about when the medication is expected to take effect is helpful but not the highest priority at this moment. Safety during ambulation is the primary concern before the client receives the medication.

Weight change in the last month:While monitoring weight changes is important in clients with depression, it is not the most critical piece of information to obtain before initiating duloxetine. Weight changes are one of many possible side effects of the medication.

Recent use of other antidepressants:Knowing about the client's previous antidepressant use is relevant, but it is not the most critical information to obtain before starting duloxetine. The choice of medication should be based on the client's current clinical condition and needs.The most important information for the nurse to obtain when planning care for a client with major depression receiving a new prescription for duloxetine is:

Family history of mental illness:
While family history can provide valuable information about a client's risk factors for mental illness, it is not the most crucial information to obtain before starting duloxetine. Assessing the client's current medical status and the potential impact of the medication on their liver function takes precedence.

Administer a narcotic reversal drug:While administering a narcotic reversal drug (such as naloxone) can be necessary if the client's respiratory depression persists or worsens, it is not the first action. The first step is to remove the source of the potential overdose, which is the excess morphine patches.The first action the nurse should take in this situation is:

Monitor blood pressure:Monitoring blood pressure is important for assessing the client's overall condition, but it is not the first action in this scenario where respiratory distress and possible narcotic overdose are the primary concerns.

Apply oxygen face mask:
Providing oxygen can help improve oxygenation, but it does not address the potential overdose caused by the excessive use of morphine patches. The priority is to remove the source of the overdose first.

Diphenhydramine:Diphenhydramine is an antihistamine commonly used to relieve allergies and may cause drowsiness. It is not indicated for heartburn or GERD symptoms.

Acetaminophen:Acetaminophen is a pain reliever and fever reducer. It is not used to address heartburn or GERD symptoms.

Low dose aspirin:Aspirin is typically used to prevent cardiovascular events in individuals at risk for heart disease but is not used to treat heartburn or GERD symptoms. In fact, aspirin can irritate the stomach lining and potentially worsen heartburn symptoms.

Use a pulse oximeter to assess oxygen saturation:Oxygen saturation assessment is unrelated to the observation of jaundice. Jaundice primarily indicates a potential liver issue, not an oxygenation problem.When a nurse observes that a client taking acetaminophen for chronic pain has yellowish skin (jaundice), the appropriate action is:

Advise the client to reduce the medication dose:In cases of jaundice, reducing the medication dose may not be sufficient. A healthcare provider needs to evaluate the client's liver function and determine the appropriate course of action.

Check the client's capillary glucose level:
Assessing the capillary glucose level is not relevant to the observation of jaundice. Jaundice is related to liver function and bilirubin metabolism, while glucose levels are related to diabetes management or other glucose-related issues.

Consulting with a pharmacist about scheduling the dose one hour after the client eats:While it is important to take risedronate on an empty stomach, waiting one hour after eating is insufficient. The recommendation is to take it first thing in the morning, at least 30 minutes before any other food or drink, including milk.

Withholding the medication until the client's breakfast tray is available on the unit:Delaying the administration of risedronate until breakfast may not align with the recommended dosing instructions, which specify taking it in the morning on an empty stomach. Delaying the medication could affect its effectiveness.

Assigning unlicensed assistive personnel (UAP) to bring the client a glass of low-fat milk:Providing milk or other beverages with risedronate is not appropriate, as it can interfere with the medication's absorption. Instructing the client to take it with water alone is the correct approach.The correct action for the nurse to take when the client with osteoporosis asks for a glass of milk to drink with risedronate is:

Apply a telemetry monitor before administering the dose:While monitoring the client's heart rate is important, applying a telemetry monitor may not be necessary at this stage. The primary concern is addressing the bradycardia and elevated blood pressure by notifying the healthcare provider.

Administer the dose and monitor the client's BP regularly:Administering the dose without addressing the low heart rate and inadequate blood pressure control may not be safe. The healthcare provider should be consulted before proceeding.The action the nurse should take when preparing to administer a scheduled dose of labetalol to a client with hypertension, with vital signs including a heart rate of 48 beats/minute and a blood pressure of 150/90 mm Hg, is:

Assess for orthostatic hypotension before administering the dose:
While orthostatic hypotension assessment is important when starting antihypertensive medications, it does not address the immediate concerns of bradycardia and elevated blood pressure. The healthcare provider should be notified before administering the medication.

Dizziness:While dizziness can be a side effect of ibuprofen, it is generally less serious than vomiting blood. Dizziness should still be reported, but it is not as urgently concerning as hematemesis.

Nausea:Nausea is a common side effect of ibuprofen and can occur due to its effects on the stomach lining. While it should be reported, it is not as immediately concerning as vomiting blood.

Insomnia:Insomnia is not typically associated with ibuprofen use and is generally less concerning in this context. It should be addressed but is not a sign of a potentially life-threatening condition.In summary, the presence of hematemesis is a critical finding that suggests significant gastrointestinal bleeding and requires immediate medical attention when a client is taking ibuprofen.
The finding that is most important for the nurse to report to the healthcare provider when caring for a client who has been taking ibuprofen is:

Lorazepam:Lorazepam is a benzodiazepine used for its anxiolytic and sedative effects. It is not known to cause AKI. Monitoring for sedation and respiratory depression may be necessary, but this is unrelated to kidney function.The client the nurse should closely monitor for the development of acute kidney injury (AKI) when administering medications is:

Sucralfate:Sucralfate is a medication used to treat and prevent gastrointestinal ulcers. It is not typically associated with AKI. Monitoring for gastrointestinal side effects is more relevant when administering sucralfate.

Digoxin:
Digoxin is a medication used to treat heart conditions. While it can affect renal function, it is not a primary cause of AKI. Monitoring serum digoxin levels and assessing for signs of digoxin toxicity are important when administering digoxin, but it is not the primary concern for AKI.

Cover your skin before going outside:This instruction is not directly related to spironolactone or hyperaldosteronism. It may be relevant for clients taking photosensitizing medications but is not specific to this situation.

Monitor skin for excessive bruising:
This instruction is also not directly related to spironolactone or hyperaldosteronism. It may be relevant in other clinical contexts, but it does not address the potential side effects or management of spironolactone.

Replace salt with a salt substitute:While reducing sodium intake is often recommended for clients with heart failure, replacing salt with a salt substitute containing potassium is not advisable for clients taking spironolactone. This would increase the risk of hyperkalemia.

Serum glucose level of 120 mg/dL (6.7 mmol/L):This glucose level is within the reference range and is not directly related to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.

Serum ammonia level of 30 Mcg/dL (17.62 Mamal /dL):Serum ammonia levels are not typically affected by sodium polystyrene sulfonate, and this value is within the reference range.When administering sodium polystyrene sulfonate to a client with acute kidney injury (AKI), the medication is used to help lower elevated potassium levels (hyperkalemia). Therefore, the laboratory finding that indicates the medication has been effective is:

Hemoglobin level of 13.5 g/dl (135 g/L):
Hemoglobin levels are unrelated to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia. This hemoglobin level is within the reference range.

Peripheral edema:Peripheral edema (swelling of the extremities) is not a typical symptom of muscle damage associated with statin use. It is more commonly associated with other cardiovascular or renal conditions.

Excessive bruising is not a typical symptom of muscle damage related to statin use. It is more commonly associated with bleeding disorders or certain medications, such as anticoagulants.

Nausea and vomiting:Nausea and vomiting are not typical symptoms of muscle damage associated with statin use. They are more commonly associated with gastrointestinal side effects or other unrelated issues.

Increases the strength of the urine stream:This is not the purpose of probenecid. Probenecid primarily affects uric acid metabolism in the body, not the strength of the urine stream.The nurse should explain the purpose of probenecid, a uricosuric drug, as:

Prevents the formation of kidney stones:While probenecid may indirectly reduce the risk of certain types of kidney stones associated with high uric acid levels, its primary purpose is not to prevent kidney stone formation. It is used to manage conditions like gout and hyperuricemia.

Decreases pain and burning during urination:
Probenecid does not have a direct effect on pain and burning during urination. These symptoms are typically associated with urinary tract infections or other urinary conditions, not gout or hyperuricemia managed with probenecid.

Obtain daily weights:Daily weights are more relevant for monitoring fluid balance and assessing for edema, which is not a common adverse reaction to tamsulosin.

Perform a bladder scan:Bladder scans may be used to assess for urinary retention or post-void residual urine, but this is not a primary intervention to monitor for adverse reactions to tamsulosin.

Assess urine output:Monitoring urine output is important to assess for urinary retention or changes in urinary function, but it is not the primary intervention for monitoring adverse reactions to tamsulosin.When a client with benign prostatic hyperplasia (BPH) receives a new prescription for tamsulosin, the nurse should perform the following intervention to monitor for an adverse reaction:

Both medications should be held in the presence of significant hypercalcemia. Administering calcium in this situation can exacerbate the elevated calcium levels.When the nurse notes that a client with hypoparathyroidism has a total calcium level of 14 mg/dL (3.5 mmol/L), which is above the reference range (normal range for adults: 9 to 10.5 mg/dL or 2.25 to 2.62 mmol/L), the appropriate action is:

Holding only one of the medications is not appropriate when the client has hypercalcemia. Both medications should be withheld pending further evaluation by the healthcare provider.

Administering both medications when the client has hypercalcemia can worsen the condition and is not appropriate. Hypercalcemia requires intervention and close monitoring.

Hypertension:Hypertension (high blood pressure) is not typically associated with piperacillin-tazobactam. While monitoring blood pressure is important during infusions, it is not a reason to stop the infusion on its own.

Pupillary constriction:Pupillary constriction (miosis) is not a common adverse reaction to piperacillin-tazobactam. It is not a primary reason to stop the infusion.When a client receiving an infusion of piperacillin-tazobactam for a urinary tract infection reports not feeling well, the manifestation that the nurse should identify as a reason to stop the infusion is:

Scratchy throat:
A scratchy throat could be a sign of an allergic reaction but is not specific to piperacillin-tazobactam. Other signs of an allergic reaction, such as rash, itching, swelling, or difficulty breathing, would be more concerning. In such cases, the infusion should be stopped and appropriate interventions initiated.

Unpleasant smell when using the medication:While acetylcysteine has a distinctive odor, this is not the primary therapeutic response to expect. The odor is often described as unpleasant or sulfur-like.

Bronchodilation and wheezing:Acetylcysteine is not primarily used for bronchodilation. It is used to thin mucus and facilitate its removal. Wheezing is not a common response to acetylcysteine.When administering acetylcysteine via nebulization through an endotracheal tube to a client with pneumonia, the nurse should expect the following therapeutic response:

Hypotension:
Hypotension is not a common or expected therapeutic response to acetylcysteine. It is important to monitor blood pressure during administration, but hypotension is not the primary effect of this medication.

Monitor for electrolyte imbalance:Sucralfate is not typically associated with causing electrolyte imbalances. Monitoring for electrolyte imbalances may be relevant for other medications or conditions, but it is not a primary consideration for sucralfate.

Administer sucralfate once a day, preferably at bedtime:
The typical dosing regimen for sucralfate involves multiple daily doses, not once a day. The timing of the doses is important, but once-daily dosing is not recommended.

Assess for secondary Candida infection:Sucralfate is not associated with an increased risk of secondary Candida (fungal) infections. Candida infections are more commonly associated with the use of antibiotics or immunosuppressive medications.

Breastfeeding is not recommended while taking this medication:While it's important to avoid breastfeeding while taking isotretinoin due to potential risks to the infant, the priority in this scenario is preventing exposure to the medication during pregnancy.The most important information for the nurse to provide to a young adult female client planning to become pregnant while taking isotretinoin for cystic acne is:

Do not take multiple vitamins that contain vitamin A while taking this drug:Avoiding excessive vitamin A intake is important to prevent vitamin A toxicity, but it is not the most critical piece of information for a client planning to become pregnant while on isotretinoin.

Baseline liver function results must be obtained during therapy:
Monitoring liver function is important during isotretinoin therapy, but the priority in this scenario is preventing fetal exposure to the medication by discontinuing it before attempting pregnancy.

Remind the client to drink plenty of fluids when taking the medication:Drinking fluids with zolpidem is not a primary concern in this situation. The main issue is the timing of the medication. When a client with a new prescription for zolpidem, a hypnotic, plans to take a dose of the medication during the day for a short afternoon nap, the nurse should take the following action:

Advise the client to take the medication with the noon meal:Zolpidem is not typically taken with meals. Again, the primary concern is the timing of the medication.

Explain that the client needs to allow for sleep time of at least two hours:
While it's important to allow for sufficient sleep time after taking zolpidem to minimize the risk of impaired alertness and coordination, the client should be encouraged to take the medication at bedtime rather than during the day to ensure it works as intended.

Remind the client to drink plenty of fluids when taking the medication:Drinking fluids with zolpidem is not a primary concern in this situation. The main issue is the timing of the medication.When a client with a new prescription for zolpidem, a hypnotic, plans to take a dose of the medication during the day for a short afternoon nap, the nurse should take the following action:

Advise the client to take the medication with the noon meal:Zolpidem is not typically taken with meals. Again, the primary concern is the timing of the medication.

Explain that the client needs to allow for sleep time of at least two hours:
While it's important to allow for sufficient sleep time after taking zolpidem to minimize the risk of impaired alertness and coordination, the client should be encouraged to take the medication at bedtime rather than during the day to ensure it works as intended.

Take with milk or antacids to prevent gastrointestinal (GI) irritation:Tetracycline should not be taken with milk or antacids because these can bind to the medication and reduce its absorption. It is generally recommended to take tetracycline with a full glass of water on an empty stomach, unless otherwise instructed by the healthcare provider.When providing instructions to a client prescribed tetracycline HCl, the nurse should include the following instruction:

Return to the clinic weekly to obtain serum drug levels:Routine monitoring of serum drug levels is not typically required for clients taking tetracycline. Monitoring may be necessary for other medications, but it is not a standard practice for tetracycline.

Take with orange juice to enhance GI absorption:
Like milk and antacids, taking tetracycline with orange juice can interfere with its absorption. It is generally recommended to take tetracycline with a full glass of water on an empty stomach for optimal absorption.

Assess the client's vital signs:While monitoring vital signs is important in the overall care of the client, the increase in the white blood cell count alone does not warrant immediate vital signs assessment. Vital signs would be assessed as part of routine nursing care, but they are not the primary concern in this scenario.

Neutropenic precautions are typically implemented when the client has a low white blood cell count (neutropenia), not when the white blood cell count is increasing in response to treatment. In this case, the increase in white blood cells is a desired therapeutic effect.

Review the client's culture and sensitivity reports:Reviewing culture and sensitivity reports is important in cases of infection, but it is not the immediate action to take in response to the increased white blood cell count. The increase in white blood cells indicates a positive response to treatment, but it does not provide information about the presence or type of infection.

Evaluate muscle strength every 4 hours:While monitoring muscle strength is essential in assessing the client's response to treatment and potential side effects, checking it every 4 hours may not be necessary and can disrupt the client's rest. Assessing muscle strength as part of the overall neurological assessment at regular intervals is appropriate.

Monitor intake and output every 8 hours:Monitoring intake and output is essential for assessing hydration status, but it is not directly related to the administration of baclofen. It is a routine nursing assessment and should not be tied specifically to this medication.When administering the muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis, the nurse should implement the following intervention:

Ensure the client knows to stop baclofen before using other antispasmodics:
It is essential for the client to be aware of their medications and potential interactions, but stopping baclofen or any medication should be done under the guidance of a healthcare provider. The nurse should educate the client about the importance of discussing all medications and potential interactions with their healthcare provider but should not instruct them to stop any medication without medical advice.