A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin?

Give the dose over 60 min.

Administer the medication undiluted.

Inject 19% lidocaine prior to each dose.

Obtain a trough level 30 min after the medication infusion.

Answer and Explanation

The Correct Answer is A

A.   Administering vancomycin over a longer infusion time, such as 60 minutes, can help reduce the risk of adverse reactions, such as red man syndrome or nephrotoxicity. Slower infusion rates allow for better tolerance of the medication.
B.   Vancomycin should be diluted appropriately before administration to reduce the risk of infusion-related reactions.
C.   Lidocaine is not typically used prior to vancomycin administration. The use of lidocaine would be more relevant for local anesthesia, not for systemic medication administration like vancomycin.

D.   Trough levels are typically obtained just before the next dose of vancomycin is due, not immediately after the infusion.

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Correct Answer is D

Explanation

A: Elevated toilet seats are often recommended following hip surgery to reduce strain, not increase the risk of injury.
B: No stairs in the home is generally a positive feature for a client following hip surgery, reducing fall risk.
C: A reclining chair with a straight back may provide comfortable seating without increasing the risk of injury.
D: A large soaking tub without a shower head can increase the risk of falls and injury due to difficulty getting in and out of the tub, especially for a client recovering from hip surgery.

A. "Take your temperature immediately after waking and before getting out of bed." B. "Take your temperature 1 hour after getting out of bed." C. "Take your temperature every night before going to bed." D. "Take your temperature within 30 minutes after your first morning void."

Correct Answer is A

Explanation

A. Basal body temperature should be measured immediately upon waking and before any physical activity to ensure accuracy in detecting the slight temperature rise after ovulation.
B. Temperature taken after getting out of bed may not accurately reflect the basal body temperature.
C. Basal body temperature is best measured in the morning.

D. The timing here still allows for too much activity before measuring temperature, which can affect the reading.

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A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin?

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Naxlex Comprehensive Predictor Exams

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