Patient Data

Exhibits

The nurse is preparing the client's plan of care (POC).

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

No known allergies

Used for prophylaxis

Potassium 4.4 mEq/L (4.4 mmol/L)

Dosage in safe range

Peripheral IV (PIV) in large vein

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

Answer and Explanation

Correct Answer : A,D,E,F

A. No known allergies: Confirming the client has no allergies to vancomycin or related substances is critical for safe administration. Administering an antibiotic to a client with a known allergy could result in life-threatening anaphylaxis.

B. Used for prophylaxis: Although vancomycin is often used prophylactically before procedures to prevent infection, the indication alone does not ensure that it is safe to administer. Safety focuses more on client-specific factors like allergies and organ function.

C. Potassium 4.4 mEq/L (4.4 mmol/L): This is a normal potassium level and reflects good electrolyte balance but does not directly relate to the safety of administering vancomycin, which is more concerning for kidney function and allergic reactions.

D. Dosage in safe range: Verifying that the vancomycin dose is within the recommended therapeutic range is essential to prevent toxicity, particularly nephrotoxicity and ototoxicity, which are risks with improper dosing.

E. Peripheral IV (PIV) in large vein: Administering vancomycin through a large-bore IV in a large vein reduces the risk of phlebitis and tissue irritation. Proper venous access is an important safety consideration when giving this medication.

F. Blood urea nitrogen 17 mg/dL (6.07 mmol/L): A normal BUN level suggests that renal function is adequate. Since vancomycin is primarily excreted by the kidneys, good renal function supports safe medication clearance and reduces toxicity risk.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Contact the healthcare provider (HCP) immediately if suicidal thoughts occur: Antidepressants like sertraline can increase the risk of suicidal thoughts, especially during the early stages of treatment. Immediate reporting of such thoughts is critical to ensure the client’s safety and prevent harm.

B. Contact the healthcare provider (HCP) immediately if muscle stiffness occurs: Although rare, muscle stiffness could signal serotonin syndrome if occurs with a constellation of symptoms including confusion, agitation, fever, sweating and tremors, not just stiffness. Suicidal ideation presents a more immediate and life-threatening risk in clients starting antidepressants and requires the highest priority.

C. Increase activity level to include a daily exercise routine: While exercise is beneficial for managing depression, it is supportive therapy and not the most urgent teaching point compared to recognizing and reporting suicidal ideation associated with antidepressant use.

D. Avoid processed meats, red wine, and Swiss cheese: This dietary restriction is necessary when taking monoamine oxidase inhibitors (MAOIs) to prevent hypertensive crises. Sertraline is a selective serotonin reuptake inhibitor (SSRI), so these dietary precautions are not required.

A. Ask the client to describe her dietary intake history for the last several days. B. Instruct the client to increase her intake of saturated fats over the next week. C. Advise the client to stop taking the drug and contact her healthcare provider (HCP). D. Obtain a stool specimen to evaluate for occult blood and fat content.

Correct Answer is A

Explanation

A. Ask the client to describe her dietary intake history for the last several days: Orlistat works by inhibiting fat absorption, and excessive intake of dietary fats can cause oily stools and gas. Assessing the client’s recent diet helps determine if her symptoms are due to high fat consumption, which can then be managed through dietary adjustments.

B. Instruct the client to increase her intake of saturated fats over the next week: Increasing fat intake would likely worsen her symptoms, as orlistat prevents fat absorption, leading to more pronounced gastrointestinal side effects if fat intake remains high.

C. Advise the client to stop taking the drug and contact her healthcare provider (HCP): Stopping orlistat is unnecessary at this stage. Oily stools are a common and expected side effect if dietary fat intake is not controlled, so addressing dietary habits is the first and more appropriate intervention.

D. Obtain a stool specimen to evaluate for occult blood and fat content: There is no indication that the client’s symptoms suggest gastrointestinal bleeding. The oily stools are an anticipated effect of fat malabsorption caused by orlistat, not a sign of occult blood loss.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Patient Data Exhibits The nurse is preparing the client's plan of care (POC). 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

A client with postpartum depression receives a prescription for sertraline. Which information is most important for the nurse to include in client teaching?

Correct Answer is A

Explanation

After taking orlistat for one week, a female client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. Which action should the nurse take?

Correct Answer is A

Explanation

An older adult client is being discharged after a myocardial infarction (MI) and receives a new prescription for atenolol. Which instruction is most important for the nurse to include in this client's teaching plan?

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

The mother of an adolescent male tells the clinic nurse that she found anabolic steroids in her son's room. How should the nurse respond? Select all that apply.

After receiving the third dose of a new oral anticoagulant prescription, an older adult client develops bleeding and tender gums and has many new bruises. Which action(s) should the nurse implement? Select all that apply.

After administering nitroglycerin spray to a client experiencing angina, which action should the nurse implement next?

An adolescent receives a new prescription for isotretinoin for cystic acne. Which information is most important for the nurse to provide?

A client taking atorvastatin develops an increased serum creatine phosphokinase (CK) level. The nurse should assess the client for the onset of which problem?

Patient Data

Exhibits

The nurse is preparing the client's plan of care (POC).

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