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Patient Data

Exhibits

The nurse is preparing the client’s plan of care. Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

No known allergies

Dosage in safe range

Potassium 4.4 mEq/L (4.4 mmol/L)

Peripheral IV in large vein

Used for prophylaxis

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

Answer and Explanation

Correct Answer : A,B,D,E

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.

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Correct Answer is C

Explanation

Choice A Reason:

Checking for the correct placement of the patch behind the client’s ear is important to ensure proper administration of the medication. However, this action does not address the client’s concern about pain relief. Scopolamine is used to prevent nausea and vomiting, not to manage pain. Therefore, while correct placement is necessary, it does not explain why the client is still experiencing pain.

Choice B Reason:

Offering to apply a new transdermal patch to relieve the pain is not appropriate because scopolamine is not intended for pain relief. Applying a new patch would not address the client’s pain and could lead to unnecessary medication use. The nurse should clarify the purpose of the medication instead.

Choice C Reason:

Explaining that the medication is not given to prevent pain is the correct action. Scopolamine is an anticholinergic medication used to prevent nausea and vomiting associated with motion sickness and recovery from anesthesia. It is not an analgesic and does not provide pain relief. The nurse should inform the client about the intended use of the medication and address pain management separately.

Choice D Reason:

Advising the client that the effects of the medication have worn off is incorrect. Scopolamine patches are designed to release medication over a period of up to 72 hours. The effects would not wear off within a few hours. This statement does not address the client’s misunderstanding about the purpose of the medication.

A. Take on an empty stomach at least 1 hour before meals. B. Administer an additional dose if a dose is missed. C. Schedule doses with each meal and at bedtime. D. Continue with normal dose schedule after missing a dose.

Correct Answer is A

Explanation

Choice A reason:

Taking sucralfate on an empty stomach at least 1 hour before meals is crucial for its effectiveness. Sucralfate works by forming a protective barrier over ulcers, and food can interfere with this process. Therefore, it is recommended to take sucralfate on an empty stomach to ensure maximum efficacy.

Choice B reason:

Administering an additional dose if a dose is missed is incorrect. If a dose is missed, it should be taken as soon as possible. However, if it is almost time for the next dose, the missed dose should be skipped, and the regular dosing schedule should be resumed. Doubling up on doses can lead to potential side effects and complications.

Choice C reason:

Scheduling doses with each meal and at bedtime is not appropriate for sucralfate. This medication should be taken on an empty stomach, not with meals. Taking it with food can reduce its effectiveness in treating peptic ulcers.

Choice D reason:

Continuing with the normal dose schedule after missing a dose is partially correct but lacks the specific instruction to skip the missed dose if it is almost time for the next one. The correct approach is to take the missed dose as soon as possible unless it is close to the next scheduled dose.

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Patient Data Exhibits The nurse is preparing the client’s plan of care. 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 male client receives a scopolamine transdermal patch 2 hours before surgery. Four hours after surgery, the client tells the nurse that he is experiencing pain and asks why the patch is not working. Which action should the nurse take?

Correct Answer is C

Explanation

The nurse is caring for a client receiving a prescription for sucralfate to treat a peptic ulcer. Which instruction should the nurse provide during discharge education?

Correct Answer is A

Explanation

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Patient Data

Exhibits

The nurse is preparing the client’s plan of care. Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.