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.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Evaluate muscle strength every 4 hours: While assessing muscle strength is important in clients with multiple sclerosis, it does not need to be done this frequently unless the client is unstable. Baclofen may cause weakness, but routine assessments every 4 hours are excessive for stable patients.

B. Advise the client to move slowly and cautiously when rising and walking: Baclofen can cause dizziness, sedation, decreased muscle tone and orthostatic hypotension, particularly in the early stages of treatment. Educating the client to change positions carefully helps reduce the risk of falls and injury.

C. Ensure the client knows to stop baclofen before using other antispasmodics: Baclofen should not be stopped abruptly due to the risk of withdrawal symptoms like hallucinations or seizures. Combining different antispasmodic medications can increase the risk of adverse effects such as excessive sedation or muscle weakness. Medication changes therefore should only be made under the supervision of the healthcare provider.

D. Monitor intake and output every 8 hours: Baclofen does not typically affect renal function or fluid balance significantly. Monitoring intake and output is not a standard intervention specific to baclofen administration unless there is another underlying condition.

A. Gingko biloba use should be limited and not taken during pregnancy. B. Nausea and diarrhea can occur when using this supplement. C. Anxiety and headaches increase with the use of ginkgo. D. Aspirin and nonsteroidal antiinflammatory drugs (NSAID) interact with ginkgo.

Correct Answer is D

Explanation

A. Gingko biloba use should be limited and not taken during pregnancy: While this is true, the client in question is using it for multiple sclerosis-related symptoms and not indicated to be pregnant. This point is valid but not the most immediate safety concern for her situation.

B. Nausea and diarrhea can occur when using this supplement: These are known side effects of ginkgo biloba but are generally mild and not life-threatening. They are less critical to emphasize than potentially dangerous drug interactions.

C. Anxiety and headaches increase with the use of ginkgo: While some users may experience headaches, the occurrence of anxiety is less common. These effects are not as significant or dangerous as those involving bleeding risks when ginkgo is combined with other medications.

D. Aspirin and nonsteroidal antiinflammatory drugs (NSAID) interact with ginkgo: Ginkgo biloba has antiplatelet properties and can increase the risk of bleeding, especially when taken with aspirin or NSAIDs. This interaction is potentially serious and is the most important safety information to provide.

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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

The nurse is administering the muscle relaxant baclofen PO to a client diagnosed with multiple sclerosis. Which intervention should the nurse implement?

Correct Answer is B

Explanation

A female client with multiple sclerosis reports having less fatigue and improved memory since she began using the herbal supplement, ginkgo biloba. Which information is most important for the nurse to include in the teaching plan for this client?

Correct Answer is D

Explanation

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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.