A patient with a confirmed MRSA skin infection is being treated with vancomycin. What nursing action is most critical to ensure the effectiveness of the treatment?
Educating the patient about completing the full course of antibiotics.
Obtaining cultures and sensitivities before starting the antibiotic.
Administering the medication at the exact scheduled time.
Monitoring the patient's renal function.
The Correct Answer is C
A. Educating the patient about completing the full course of antibiotics: This is a crucial education point for all antibiotics to prevent resistance but is not the most critical specific nursing action to ensure the effectiveness of vancomycin therapy.
B. Obtaining cultures and sensitivities before starting the antibiotic: This is a necessary step in the initial management of infection to confirm the pathogen and guide therapy, but since the question states the infection is "confirmed MRSA" and the patient "is being treated with vancomycin," this step has likely already occurred.
C. Administering the medication at the exact scheduled time: Vancomycin requires precise dosing intervals to maintain the necessary therapeutic drug level (Trough) in the blood, making timely administration important. However, monitoring is key.
D. Monitoring the patient's renal function: This is the most critical nursing action. Vancomycin is nephrotoxic (toxic to the kidneys). To ensure the effectiveness of treatment while preventing toxicity, the nurse must monitor the patient's BUN and Creatinine (renal function) and ensure that peak and trough drug levels are drawn as ordered. The trough level (the lowest level) is especially critical as it confirms the dose is effective without being toxic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Apply alcohol-based lotion to dry out the site: Alcohol is cytotoxic and irritating and would likely worsen the irritation and could harm the healing abrasion.
B. Apply a thick, occlusive dressing to prevent exposure: An occlusive dressing would trap the increased drainage and moisture against the skin, which would lead to maceration and worsening of the irritation.
C. Increase the frequency of bathing to keep the area clean: While cleanliness is important, excessive bathing can dry out the skin and does not directly address the localized issue beneath the bandage.
D. Change the bandage and clean the area with an antiseptic:The nurse must remove the soiled bandage to visualize and assess the wound and surrounding skin (for signs of infection, maceration, or inflammation). The area should then be gently cleansed (with saline or an appropriate wound cleanser) and a new, appropriate dressing applied to manage the increased drainage.
Correct Answer is A
Explanation
A. Reposition the patient every 2 hours and use pressure redistribution devices:The formation of a Stage I pressure injury means the current pressure relief regimen is inadequate. The immediate priority is to offload the pressure (repositioning every 2 hours or more frequently) and utilize pressure redistribution devices (e.g., specialized mattresses or cushions) to prevent further tissue damage and allow the skin to recover.
B. Apply alcohol-based cream to the area: Alcohol is drying and irritating and can damage the already compromised skin.
C. Elevate the head of the bed to 45°: Elevating the head of the bed above 30 degrees increases shear and friction on the sacrum, which is a major contributing factor to pressure injury formation.
D. Gently rub the area to increase circulation:Massaging a reddened, nonblanchable area can cause further deep tissue injury by damaging capillaries and underlying tissue.
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