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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.