Exhibits

The nurse collects blood from the client during peripheral IV line placement. What laboratory specimens would the nurse expect for the provider to order? Select all that apply.

Are you fully insured?

Is it possible that you are pregnant?

Do you take any medications?

What was your last meal?

What happened before you fell?

Do you live with anyone?

Answer and Explanation

Correct Answer : A,B,D,F

A. Peripheral IV in large vein
Vancomycin should be administered through a large-bore IV to minimize the risk of complications such as phlebitis and to ensure effective drug delivery. This is a key factor in safely administering the medication.
B. Dosage in safe range
Confirming that the dosage is within the safe range ensures that the medication is administered at an effective but non-toxic level. Proper dosing is essential for achieving therapeutic effects without causing harm.
C. No known allergies
Ensuring that the client has no known allergies to vancomycin is critical to prevent allergic reactions. This step is necessary for the safe administration of the antibiotic.
D. Potassium 4.4 mEq/L (4.4 mmol/L)
While normal potassium levels are important for overall health, they do not specifically indicate the safety of vancomycin administration. Other factors such as IV access and dosage are more directly related to the safety of vancomycin.
E. Used for prophylaxis
Vancomycin is used for endocarditis prophylaxis in this case, which aligns with the clinical guidelines for preventing infections. Understanding the purpose of the medication supports its appropriate use in the client’s care.
F. Blood urea nitrogen 17 mg/dL (6.07 mmol/L)
An elevated BUN level might indicate renal impairment, which could affect vancomycin metabolism. However, this level alone does not directly address the immediate safety of administering the antibiotic compared to other factors like IV access and dosage.

Nursing Test Bank

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Correct Answer is C

Explanation

A. Positions the wrapped package on the bedside table so the outer flap is away from her: This action is correct because opening the flap away from the body minimizes the risk of contaminating the sterile field.

B. Holds gauze packages 15 cm (6 in) above the sterile field: This action is correct. Dropping sterile items from a height of 6 inches or more prevents contamination by ensuring they do not touch the edges or outside surfaces of the sterile field.

C. Holds a bottle of solution with the label away from the palm of the hand: When pouring a solution, the label should be held toward the palm of the hand to protect it from damage caused by spills. A damaged label could make it difficult to identify the solution, increasing the risk of error.

D. Wears sterile gloves when moving sterile items on the sterile field: This action is appropriate. Sterile gloves help maintain the sterility of the field and are required when manipulating sterile items.

A. Pernicious anemia B. Prostate enlargement C. Dehydration D. Bladder infection

Correct Answer is D

Explanation

A. Pernicious anemia is a condition related to vitamin B12 deficiency and does not typically cause blood-tinged urine.
B. Prostate enlargement (benign prostatic hyperplasia) can cause urinary symptoms like hesitancy and frequency but does not directly cause blood-tinged urine.
C. Dehydration can lead to concentrated urine and urinary tract irritation but does not typically cause blood-tinged urine.
D. Blood-tinged urine in a client with an indwelling urinary catheter is concerning for a bladder infection, especially if accompanied by other signs like fever or foul odor.

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Exhibits The nurse collects blood from the client during peripheral IV line placement. What laboratory specimens would the nurse expect for the provider to order? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

Correct Answer is C

Explanation

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

Correct Answer is D

Explanation

A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?

A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first?

A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients?

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor?

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

A nurse is assessing a client to identify risk factors for disease. Which of the following findings is a risk factor for metabolic syndrome?

A nurse manager is providing an educational program on antibiotic sensitivity to bacterial infections. The nurse should include in the teaching that vancomycin is indicated for which of the following infections?

Exhibits

The nurse collects blood from the client during peripheral IV line placement. What laboratory specimens would the nurse expect for the provider to order? Select all that apply.