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.

Dosage in safe range

Peripheral IV in large vein

No known allergies

Used for prophylaxis

Blood urea nitrogen 17 mg/dL (6.07 mmol/L)

Potassium 4.4 mEq/L (4.4 mmol/L)

Answer and Explanation

Correct Answer : A,B,C,E

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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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"C"},"G":{"answers":"C"}}

Explanation

The reported slight rectal burning sensation after the administration of a bisacodyl suppository is likely a non-therapeutic side effect. This sensation is a common reaction to rectal medication administration and not directly related to the therapeutic effects of lactulose.
A large, soft stool can be considered a therapeutic result of lactulose, which is often prescribed as a laxative to treat constipation. Its effectiveness is indicated by the production of soft stools.
Dizziness experienced by the patient after requesting to use the restroom could be an unrelated finding or a non-therapeutic side effect. Given that morphine was administered, which can cause dizziness as a side effect, it is important to consider all medications and their interactions when assessing this symptom.
A pain level of 3 on a 0 to 10 pain scale is an unrelated finding concerning the administration of lactulose. Pain assessment is subjective and can be influenced by various factors unrelated to lactulose treatment.
The voiding of 600ml of urine is an unrelated finding to the lactulose treatment. Urine output is influenced by many factors, including fluid intake and other medications.
An abdomen that is soft and flat is an unrelated finding to the lactulose treatment. This is a normal physical examination finding and does not directly correlate with the administration of lactulose.
A respiratory rate of 13 breaths/min is also an unrelated finding to the lactulose treatment. The normal respiratory rate for an adult is typically between 12 to 20 breaths per minute.

A. Demonstrate how to select dose based on before meal blood sugar readings. B. Provide information on increasing medication dosage if ketoacidosis occurs. C. Teach the client self-injection skills for daily subcutaneous administration. D. Explain to the family how to inject this medication for severe hypoglycemia.

Correct Answer is C

Explanation

A. Insulin glargine is a long-acting insulin and is not adjusted based on before meal blood sugar readings; it's typically administered once daily at the same time each day.
B. Adjusting medication dosage for ketoacidosis is not appropriate; insulin glargine is used for baseline blood glucose control, and ketoacidosis requires specific management.
C. Insulin glargine is administered subcutaneously and requires teaching on proper self-injection techniques.
D. Insulin glargine is used for long-term glucose control, not for managing acute severe hypoglycemia, so teaching family injection for hypoglycemia is not relevant here.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Review H and P, nurse's notes, flow sheet, and prescriptions. Mark whether the assessment finding represents a therapeutic result of the lactulose administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have only one option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"C"},"G":{"answers":"C"}}

Explanation

The nurse is planning discharge teaching for a client with type 2 diabetes mellitus who has a new prescription for insulin glargine. Which action should the nurse plan to include in the discharge teaching?

Correct Answer is C

Explanation

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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.

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An older client with heart failure (HF), coronary artery disease (CAD), and hypertension (HTN), is receiving these daily prescriptions: atenolol, furosemide, and enalapril. Which assessments should the nurse include in evaluating the effectiveness of the medications? (Select all that apply.)

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.