A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?
“I can adjust the time and schedule for when it’s convenient for you.”.
“I can start the medication 30 minutes earlier.”.
“I have up to 2 hours after the usual schedule time to give you this medication.”.
“I can infuse the medication at a faster rate.”.
None
None
The Correct Answer is B
Choice A rationale: Adjusting medication times based solely on convenience violates the prescribed dosing interval, which is essential for maintaining therapeutic drug levels and preventing antibiotic resistance or toxicity.
Choice B rationale: Facility policies typically allow a "grace period" for non-time-critical medications, usually 30 to 60 minutes before or after the scheduled time, to ensure safe and timely administration.
Choice C rationale: Administering a medication 2 hours late significantly deviates from the prescribed schedule, potentially causing the drug's plasma concentration to fall below the minimum effective level required for treatment.
Choice D rationale: Increasing the infusion rate of vancomycin is dangerous and can cause "Red Man Syndrome," a hypersensitivity reaction characterized by flushing, rash, and hypotension due to rapid histamine release.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
B, C, and D. These findings require follow-up because they indicate possible complications of chemotherapy, such as infection, low blood cell counts, and lung damage.
Choice B is correct because a temperature of 38.6° C (101.5° F) is a sign of fever, which can indicate an infection. Chemotherapy can weaken the immune system and make the client more prone to infections.
Choice C is correct because a WBC count of 3,800/mm3 is below the normal range of 5,000 to 10,000/mm3 and indicates leukopenia, a condition of low white blood cells. Chemotherapy can cause leukopenia by damaging the bone marrow where blood cells are produced.
Choice D is correct because crackles heard at the bases of the lungs are abnormal breath sounds that can indicate fluid accumulation or inflammation in the lungs. Chemotherapy can cause lung damage by affecting the cells that line the airways or by triggering an immune response.
Choice A is wrong because a potassium level of 3.6 mEq/L is within the normal range of 3.5 to 5 mEq/L and does not require follow-up.
Choice E is wrong because a blood pressure of 114/56 mm Hg is within the normal range of less than 120/80 mm Hg and does not require follow-up.
Correct Answer is C
Explanation
Having interdisciplinary team meetings for the client on a regular basis.
This action best promotes communication among staff caring for the client because it allows for consistent and coordinated care planning, information sharing, and goal setting for the client who has expressive aphasia and right hemiparesis following a stroke.
Choice A is wrong because posting swallowing precautions at the head of the client’s bed does not promote communication among staff, but rather informs them of the client’s risk of aspiration due to dysphagia, which is a common complication of stroke.
Choice B is wrong because noting changes in the treatment plan in the client’s medical record is a standard practice that does not necessarily enhance communication among staff, but rather documents the client’s progress and interventions.
Choice D is wrong because recording the client’s progress in the nurses’ notes is also a standard practice that does not necessarily enhance communication among staff, but rather provides a summary of the client’s status and care.
Expressive aphasia is an acquired language disorder that affects the ability to produce spoken or written language, while right hemiparesis is a weakness or partial paralysis of the right side of the body.
Both of these conditions are caused by damage to the left hemisphere of the brain, which is responsible for language and motor control of the right side of the body. Stroke and traumatic brain injury are common causes of left hemisphere damage
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