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.”.
The Correct Answer is C
The correct answer is C. “I have up to 2 hours after the usual schedule time to give you this medication.”.
Vancomycin is an antibiotic that is used to treat serious infections caused by bacteria that are resistant to other antibiotics. It is important to maintain a steady level of vancomycin in the blood to ensure its effectiveness and prevent resistance or toxicity. Therefore, vancomycin should be given at regular intervals, usually every 12 hours, and the dose should be adjusted according to the patient’s weight and kidney function12.
However, there is some flexibility in the timing of vancomycin administration, as long as the total daily dose is given within 24 hours. According to the Mayo Clinic, "If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses."3 Therefore, the nurse can give the medication up to 2 hours after the usual schedule time, but not earlier or later.
Choice A is wrong because adjusting the time and schedule for the patient’s convenience may compromise the effectiveness of vancomycin and increase the risk of resistance or toxicity. Choice B is wrong because starting the medication 30 minutes earlier may result in a higher peak level of vancomycin in the blood, which may cause side effects such as hearing loss, kidney damage, or an allergic reaction called red man syndrome12. Choice D is wrong because infusing the medication at a faster rate may also cause a higher peak level of vancomycin in the blood and increase the risk of side effects12. Vancomycin should be infused slowly, at a rate not exceeding 10 mg per minute, over at least 60 minutes12.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Sit at or below the client’s eye level during feedings.
This action helps the client feel more comfortable and less intimidated by the nurse. It also allows the nurse to observe the client’s swallowing and signs of aspiration more easily.
Choice A is wrong because talking with the client during her feeding can distract her from swallowing properly and increase the risk of aspiration.
The nurse should encourage the client to focus on eating and avoid conversation until the feeding is over.
Choice B is wrong because discouraging the client from coughing during feedings can prevent her from clearing her airway and expelling any food particles that might have entered the trachea.
The nurse should monitor the client for coughing, choking, or changes in voice quality, which are indicators of aspiration.
Choice C is wrong because instructing the client to lift her chin when swallowing can actually make swallowing more difficult and increase the risk of aspiration.
The nurse should instruct the client to tuck her chin when swallowing, which helps close off the trachea and direct food into the esophagus.
Correct Answer is C
Explanation
The correct answer is choice C, contractions. According to the flashcards from Quizlet, a nurse should monitor a client who is at 33 weeks of gestation following an amniocentesis for contractions, as they are a sign of preterm labor and possible uterine rupture.
An amniocentesis is a procedure that involves inserting a needle into the amniotic sac to obtain a sample of amniotic fluid for testing.
It can cause complications such as bleeding, infection, leakage of fluid, and injury to the fetus or placenta.
Choice A, epigastric pain, is wrong because it is not a common complication of amniocentesis.
Epigastric pain is more likely to be associated with preeclampsia, a condition that causes high blood pressure and proteinuria in pregnancy. Epigastric pain can indicate severe preeclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), which are lifethreatening complications that require immediate medical attention.
Choice B, hypertension, is wrong because it is not a direct result of amniocentesis.
Hypertension can occur in pregnancy due to various factors, such as chronic hypertension, gestational hypertension, preeclampsia, or eclampsia. Hypertension can increase the risk of complications such as placental abruption, fetal growth restriction, preterm birth, and maternal stroke.
Choice D, vomiting, is wrong because it is not a typical complication of amniocentesis.
Vomiting can occur in pregnancy due to various causes, such as morning sickness, gastroenteritis, food poisoning, or hyperemesis gravidarum. Vomiting can lead to dehydration, electrolyte imbalance, weight loss, and malnutrition if not treated properly.
Some normal ranges that are relevant for this question are:
• The normal gestational age for delivery is between 37 and 42 weeks.
A baby born before 37 weeks is considered preterm and may have complications such as respiratory distress syndrome, bleeding in the brain, infection, or low blood sugar.
• The normal fetal heart rate is between 110 and 160 beats per minute.
A fetal heart rate below 110 or above 160 can indicate fetal distress or hypoxia.
• The normal amniotic fluid index (AFI) is between 8 and 18 cm.
An AFI below 5 cm is considered oligohydramnios and can indicate fetal growth restriction, kidney problems, or rupture of membranes.
An AFI above 24 cm is considered polyhydramnios and can indicate fetal anomalies, diabetes mellitus, or Rh incompatibility
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