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
The correct answer is choice b. "I can start the medication 30 minutes earlier."Choice A rationale: This is an inappropriate response, as the nurse should not adjust the time and schedule for the administration of alteplase recombinant, which is a time-sensitive medication used to treat a thrombus in the coronary artery. The administration of this medication must be done within a specific time frame to be effective.Choice B rationale: This is the correct answer. Alteplase recombinant is a thrombolytic medication used to dissolve blood clots in the coronary artery. It is a time-sensitive medication, and it is crucial to administer it as soon as possible to minimize the damage to the heart muscle. Starting the medication 30 minutes earlier is an appropriate action to include in the plan of care, as it can help ensure the medication is administered within the recommended time frame.Choice C rationale: This is an inappropriate response. Alteplase recombinant should be administered within a specific time frame, typically within 3 to 4.5 hours of the onset of symptoms. Waiting up to 2 hours after the usual schedule time to give the medication would be outside the recommended time frame and could potentially reduce the effectiveness of the treatment.Choice D rationale: This is an inappropriate response. Alteplase recombinant should be infused at a specific rate, as recommended by the manufacturer or healthcare provider. Infusing the medication at a faster rate could increase the risk of adverse effects and should not be included in the plan of care without specific instructions from the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. The client should keep the medication in the original container.
Dabigatran is a blood thinner that is used to prevent strokes or blood clots in people with atrial fibrillation, a type of irregular heartbeat. Dabigatran is sensitive to moisture and can lose its potency if exposed to humidity or heat. Therefore, it is important to store it in the original bottle or blister package that has a desiccant (drying agent) in the cap or cover. The client should also close the cap tightly after each use and keep the bottle away from excessive moisture, heat, and cold.
Choice A is wrong because storing the medication in the refrigerator can expose it to moisture and cause it to break down. Choice C is wrong because crushing the medication and mixing it with applesauce can alter its absorption and effectiveness. Choice D is wrong because the medication can be used up to 60 days after opening the bottle as long as it is stored properly. The normal dose of dabigatran for stroke prevention in atrial fibrillation is 150 mg twice a day, unless the client has kidney problems or other factors that require a lower dose.
Correct Answer is D
Explanation
The correct answer is choice D. Place a wedge under one of the client’s hips. This is because placing a wedge under one of the hips can help prevent compression of the inferior vena cava by the uterus, which can compromise placental blood flow and cause fetal hypoxia. Placing a wedge under the hip can also help reduce the risk of maternal hypotension, which can also affect fetal oxygenation.
Choice A is wrong because inserting a pillow under the client’s knees can increase the risk of thromboembolism, which is a potential complication of cesarean birth.
Choice B is wrong because positioning the client in reverse Trendelenburg can increase the risk of maternal aspiration, which is another potential complication of cesarean birth.
Choice C is wrong because assisting the client into the lithotomy position can also compress the inferior vena cava and reduce placental blood flow. The lithotomy position is also not necessary for cesarean birth, as the baby is delivered through an incision in the abdomen and uterus.
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