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A nurse is caring for client who has sepsis and a prescription for vancomycin 1 g in 250 mL dextrose 5% (D,W) over 2 hr by IV intermittent bolus. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer and Explanation

The Correct Answer is ["125"]

To calculate the IV pump rate:

- Total volume of dextrose solution: 250 mL

- Time for infusion: 2 hours

- The pump rate is calculated as total volume divided by time: 250/2

- This results in a pump rate of 125 mL/hr

Therefore, the nurse should set the IV pump to deliver 125 mL/hr.

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Correct Answer is C

Explanation

A. Tachypnea is not a primary sign of increased intracranial pressure but might be seen in other conditions.

B. Bilateral weakness of extremities can indicate severe brain injury but is not the most specific sign of increased intracranial pressure.

C. Decreased level of consciousness is a direct sign of increased intracranial pressure affecting brain function.

D. Hypotension is not a typical manifestation of increased intracranial pressure; increased ICP more commonly leads to hypertension.

A. A Advise the client to place one nitroglycerin tablet under his tongue as a precaution. B. B Tell the client to have someone bring him to an emergency department immediately. C. C Instruct the client to increase his intake of oral fluids until the skin flushing is relieved. D. D Reassure the client that skin flushing is a common side effect of the medication.

Correct Answer is D

Explanation

A. Advise the client to place one nitroglycerin tablet under his tongue as a precaution: Nitroglycerin is contraindicated in combination with phosphodiesterase type 5 inhibitors like tadalafil due to the risk of severe hypotension. This action could worsen the client's condition.
B. Tell the client to have someone bring him to an emergency department immediately: Skin flushing is a common side effect of tadalafil and not necessarily indicative of a medical emergency, especially in the absence of chest pain or other concerning symptoms.
C. Instruct the client to increase his intake of oral fluids until the skin flushing is relieved Increasing fluid intake is not likely to alleviate the skin flushing associated with tadalafil. This response does not address the client's concern adequately.
D. Reassure the client that skin flushing is a common side effect of the medication: Tadalafil, a phosphodiesterase type 5 inhibitor, commonly causes facial flushing as a side effect. Reassuring the client about this known side effect is appropriate, especially since he is not experiencing chest pain or other concerning symptoms.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Correct Answer is C

Explanation

A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?

Correct Answer is D

Explanation

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