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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Correct Answer is D

Explanation

A. Monitor urinary output: While monitoring output is important, it does not provide immediate diagnostic information regarding the cause of the client’s thirst. It is a supportive action but not the most efficient first step to investigate potential hyperglycemia.

B. Notify the healthcare provider (HCP): Notifying the HCP is appropriate if there are abnormal findings or the client’s condition worsens. However, the nurse should gather objective data—such as a blood glucose reading—before contacting the provider.

C. Prepare to give insulin: Insulin should not be administered without confirmation of elevated blood glucose. Giving insulin without verifying hyperglycemia could lead to serious complications, including hypoglycemia.

D. Obtain fingerstick blood glucose: Methylprednisolone, a corticosteroid, can raise blood glucose levels, and excessive thirst is a classic symptom of hyperglycemia. Checking the client’s blood glucose is the most appropriate first action to determine if elevated glucose is causing the symptom.

A. History of glaucoma. B. Taking an antiemetic medication. C. Currently pregnant. D. D Allergy to aspirin.

Correct Answer is C

Explanation

A. History of glaucoma: Glaucoma history is relevant for some medications that increase intraocular pressure, but misoprostol primarily affects the gastrointestinal and reproductive systems. It does not typically worsen glaucoma or require caution for that condition.

B. Taking an antiemetic medication: Although gastrointestinal side effects like nausea can occur with misoprostol, concurrent antiemetic use is not a contraindication. This information is less critical before the first dose compared to other more serious concerns.

C. Currently pregnant: Misoprostol is contraindicated during pregnancy because it can stimulate uterine contractions and cause miscarriage. Determining pregnancy status is crucial before administering the drug to prevent serious harm to both the client and fetus.

D. Allergy to aspirin: While clients with certain allergies require careful medication review, misoprostol is not a nonsteroidal anti-inflammatory drug (NSAID) and does not cross-react with aspirin allergies. Confirming pregnancy status is the more immediate priority.

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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

A client who is taking methylprednisolone reports feeling thirsty. Which action should the nurse take first?

Correct Answer is D

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Prior to administration of the initial dose of the gastrointestinal (GI) agent misoprostol, which information should the nurse obtain from the client?

Correct Answer is C

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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.