Exhibits

Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

Dosage in safe range

Blood urea nitrogen 17 mg/dl. (6.07 mmol/L)

Potassium 4.4 mEq/L (4.4 mmol/L)

No known allergies

Peripheral IV in large vein

Used for prophylaxis

Answer and Explanation

Correct Answer : A,B,D,E

A.   Dosage in safe range: Ensures that the dosage of vancomycin falls within the acceptable range, minimizing the risk of toxicity.
B.   Blood urea nitrogen 17 mg/dl (6.07 mmol/L): Normal BUN levels indicate adequate renal function, which is important for the excretion of vancomycin.
C.   Potassium 4.4 mEq/L (4.4 mmol/L): While potassium levels are important for overall health, they are not directly related to the administration of vancomycin.
D.   No known allergies: Absence of allergies reduces the risk of adverse reactions to the medication.
E.   Peripheral IV in large vein: A peripheral IV in a large vein allows for the administration of vancomycin without complications such as phlebitis or infiltration.
F.   While vancomycin is being used for prophylaxis against endocarditis in this case, this alone does not indicate the safety of administering the antibiotic. Other factors such as renal function and absence of allergies are more directly related to the safety of vancomycin administration.

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Correct Answer is B

Explanation

Rationale for A: Monitoring blood glucose levels is important in septic patients as hyperglycemia can occur due to stress response, and insulin resistance may develop. However, it is not the most critical intervention for immediate stabilization.
Rationale for B: Maintaining strict intake and output is crucial for a patient in septic shock because fluid balance is a key component in managing shock. Accurate measurement of intake and output ensures appropriate fluid resuscitation, which is vital for maintaining blood pressure and organ perfusion.
Rationale for C: Keeping the head of the bed raised 45 degrees can help prevent aspiration, which is particularly important in patients who are at risk of gastrointestinal bleeding or those who are sedated. However, this is not the primary intervention for septic shock management.
Rationale for D: Assessing the warmth of extremities can provide information about peripheral circulation and may indicate the effectiveness of cardiac output. Nevertheless, it is not the most immediate concern in the management of septic shock.

A. Wearing gloves when interviewing the client. B. Allowing the client to ventilate feelings. C. Encouraging the client to join a support group. D. Shaking the client's hand during an introduction.

Correct Answer is D

Explanation

A. Wearing gloves when interviewing the client. This behavior may make the client feel stigmatized or rejected, as it could imply that the nurse perceives them as contagious or untouchable.
B. Allowing the client to ventilate feelings. While this is important for emotional support, it does not directly address the psychosocial need for acceptance.
C. Encouraging the client to join a support group. This can help the client feel less isolated and gain support from others with similar experiences, but it is not as immediate or direct as personal interaction.
D. Shaking the client's hand during an introduction. This gesture of physical contact can significantly convey acceptance and normalcy, helping the client feel respected and accepted despite their condition.

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Exhibits

The nurse is implementing solutions to provide care.

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The nurse determines that the client's is still having an adverse reaction resulting in symptoms of dropdown
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Exhibits Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

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Exhibits

Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.