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Exhibits

For each body system, click tanto specify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention. Each category must have at least one response option selected.

Body system

Potential nursing intervention

Cardiovascular

Monitor vital signs continuously

Provide warmth

Echocardiogram

Defibrillator at bedside

Immunological

Administer steroid

Assess rash

IV fluids

Administer antihistamine

Respiratory

Assess lung sounds

Pain medication

Provide calm environment

Chest x-ray

Monitor vital signs continuously

Echocardiogram

Assess rash

Administer antihistamine

Assess lung sounds

Provide calm environment

Provide warmth

Defibrillator at bedside

Administer steroid

IV fluids

Pain medication

Chest x-ray

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F"]

Monitor vital signs continuously: This is crucial to detect any further changes in heart rate or blood pressure, especially given the client’s history of symptomatic bradycardia and recent hypotensive episode following vancomycin administration.

Echocardiogram: This is appropriate post-pacemaker insertion to assess cardiac function and ensure the pacemaker is functioning properly.

Immunological:

Administer antihistamine: Given the client’s adverse reaction to vancomycin, which included hives, flushing, and itching, administering an antihistamine like diphenhydramine is appropriate.

Assess rash: Monitoring the progression or improvement of the rash will help evaluate the effectiveness of the interventions and the resolution of the allergic reaction.

Respiratory:

Assess lung sounds: It's important to evaluate the client’s respiratory status, especially given the shortness of breath reported post-operatively, which could indicate a reaction to the medication or a complication from the procedure.

Provide calm environment: This intervention helps in reducing anxiety and stress, which can exacerbate symptoms and impact cardiovascular and respiratory status.

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Correct Answer is A

Explanation

A. Spironolactone is a potassium-sparing diuretic; therefore, it is important to limit potassium intake to prevent hyperkalemia.
B. Skin protection is not a specific concern related to spironolactone use.
C. Spironolactone does not commonly cause excessive bruising; monitoring for signs of hyperkalemia is more relevant.
D. Using a salt substitute may increase potassium intake, which is contraindicated with spironolactone.

A. Dosage in safe range B. Peripheral IV in large vein C. No known allergies D. Used for prophylaxis E. Blood urea nitrogen 17 mg/dL (6.07 mmol/L) F. Potassium 4.4 mEq/L (4.4 mmol/L)

Correct Answer is ["A","B","C","E"]

Explanation

A. Dosage in safe range: Ensuring that the dosage is within a safe range is crucial for preventing potential toxicity or adverse reactions.
B. Peripheral IV in large vein: Administering vancomycin through a peripheral IV in a large vein reduces the risk of phlebitis and ensures proper medication delivery.
C. No known allergies: Confirming that the client has no known allergies, especially to vancomycin or related antibiotics, is essential to avoid an allergic reaction.
D. Used for prophylaxis: While using vancomycin for prophylaxis is appropriate, this does not directly relate to safety in administration, which is more concerned with avoiding adverse reactions.
E. Blood urea nitrogen 17 mg/dL (6.07 mmol/L): A normal BUN level suggests that the kidneys are functioning properly, which is important because vancomycin is renally excreted, and impaired renal function could increase the risk of toxicity.
F. Potassium 4.4 mEq/L (4.4 mmol/L): Although within the normal range, this value does not directly impact the safety of vancomycin administration, unlike factors such as renal function or potential allergic reactions.

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Body system	Potential nursing intervention
Cardiovascular	Monitor vital signs continuously Provide warmth Echocardiogram Defibrillator at bedside
Immunological	Administer steroid Assess rash IV fluids Administer antihistamine
Respiratory	Assess lung sounds Pain medication Provide calm environment Chest x-ray

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in the client's plan of care?

Correct Answer is A

Explanation

Exhibits The nurse is preparing the client's plan of care. Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

Correct Answer is ["A","B","C","E"]

Explanation

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