A client with nasal congestion receives a prescription for phenylephrine 10 mg PO every 4 hours. Which client condition should the nurse report to the healthcare provider before administering the medication?

Choice A: No known allergies

Reason: The absence of known allergies is crucial when administering any medication, including antibiotics like vancomycin. Allergic reactions to antibiotics can range from mild rashes to severe anaphylaxis, which can be life-threatening. In this case, the patient has reported no known allergies, which significantly reduces the risk of an adverse reaction to vancomycin. This makes it safer to proceed with the administration of the antibiotic. Ensuring that the patient has no known allergies is a standard precaution in medical practice to prevent potential allergic reactions.

Choice B: Dosage in safe range

Reason: The dosage of vancomycin must be within a safe range to avoid toxicity. Vancomycin is typically dosed based on the patient’s weight and renal function. For adults, the usual dose is 15-20 mg/kg, administered every 8-12 hours, depending on the severity of the infection and the patient’s renal function. In this scenario, the prescribed dose is 1 gram in 250 mL of 0.9% sodium chloride, which is within the safe range for an adult patient. Administering the correct dosage is essential to ensure the effectiveness of the antibiotic while minimizing the risk of nephrotoxicity and ototoxicity, which are potential side effects of vancomycin.

Choice C: Potassium 4.4 mEq/L (4.4 mmol/L)

Reason: While the potassium level of 4.4 mEq/L is within the normal range (3.5-5.0 mEq/L), it is not directly related to the safety of administering vancomycin. Potassium levels are more relevant to the overall electrolyte balance and cardiac function but do not specifically impact the administration of vancomycin. Therefore, this choice is not as pertinent to the safety of vancomycin administration as the other options.

Choice D: Peripheral IV in large vein

Reason: Administering vancomycin through a peripheral IV in a large vein is important to reduce the risk of phlebitis and irritation. Vancomycin is known to be irritating to veins, and using a large vein helps to dilute the medication more effectively, reducing the risk of vein inflammation. In this case, the peripheral IV was started in the right antecubital with a 20-gauge catheter, which is appropriate for the administration of vancomycin. Ensuring proper IV placement and using a large vein can help prevent complications associated with IV administration of this antibiotic.

Choice E: Used for prophylaxis

Reason: Vancomycin is being used as a prophylactic measure to prevent endocarditis in this patient. Prophylactic use of antibiotics is common in patients undergoing certain surgical procedures, especially those with a history of heart conditions, to prevent bacterial infections. In this case, the patient is undergoing pacemaker insertion, and the use of vancomycin as prophylaxis is appropriate to prevent potential infections. Prophylactic administration of antibiotics like vancomycin is a standard practice to reduce the risk of postoperative infections, particularly in patients with a higher risk of complications.

Choice F: Blood urea nitrogen 17 mg/dl (6.07 mmol/L)

Reason: The blood urea nitrogen (BUN) level of 17 mg/dL is within the normal range (7-20 mg/dL). While BUN levels are important indicators of renal function, they are not directly related to the safety of administering vancomycin in this context. Vancomycin dosing does need to consider renal function, but the BUN level alone does not provide sufficient information to determine the safety of administration. Therefore, this choice is not as directly relevant as the other options.

The correct answer is d. Stop taking the medication if intended effect is not immediate.

Choice A Reason:

Using relaxation techniques to reduce excessive anxiety is a beneficial practice for managing generalized anxiety disorder (GAD). Techniques such as deep breathing, meditation, and progressive muscle relaxation can complement medication therapy and help reduce anxiety symptoms1. This statement does not require additional instruction as it aligns with recommended practices.

Choice B Reason:

Avoiding alcohol and other sedatives while taking lorazepam is crucial. Lorazepam is a benzodiazepine that can cause sedation and depress the central nervous system. Combining it with alcohol or other sedatives can enhance these effects, leading to dangerous levels of sedation, respiratory depression, or even overdose2. This advice is appropriate and does not need further instruction.

Choice C Reason:

Moving slowly from a sitting position to a standing position is important to prevent dizziness or lightheadedness, which can be side effects of lorazepam3. This precaution helps reduce the risk of falls and injuries, making it a suitable recommendation that does not require additional instruction.

Choice D Reason:

Stopping the medication if the intended effect is not immediate requires additional instruction. Lorazepam, like other benzodiazepines, may not produce immediate effects, especially in the context of anxiety management. It is important for clients to understand that medication may take some time to achieve the desired therapeutic effect and that abrupt discontinuation can lead to withdrawal symptoms and a potential rebound in anxiety4. The nurse should instruct the client to follow the prescribed regimen and consult their healthcare provider before making any changes to their medication.