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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 D

Explanation

Choice A reason:

Requesting a prescription to change the route of administration and use the available heparin is not appropriate. Low molecular weight heparin (LMWH) and unfractionated heparin (UFH) are not interchangeable on a unit-for-unit basis. They have different pharmacokinetics and dosing requirements. Changing the route without proper guidance can lead to incorrect dosing and potential complications.

Choice B reason:

Calculating and administering the equivalent dose of the available low molecular weight heparin is incorrect. LMWH and UFH have different dosing protocols and are not directly interchangeable. Administering LMWH instead of UFH without proper conversion and guidance can result in inappropriate anticoagulation.

Choice C reason:

Diluting the available heparin in 250 ml of normal saline solution prior to IV administration is not appropriate. The prescription specifies heparin 5000 units IV STAT, which indicates an immediate need for intravenous administration. Diluting and administering it in this manner does not align with the urgency of the order.

Choice D reason:

Advising the pharmacy of the need to deliver a vial of heparin to the nursing unit immediately is the correct action. This ensures that the client receives the prescribed medication in the correct form and dosage as ordered by the healthcare provider. It is crucial to follow the specific instructions for heparin administration to ensure patient safety and effective anticoagulation.

A. Accommodation. B. Refraction. C. Eye convergence. D. Pupillary constriction.

Correct Answer is D

Explanation

Choice A Reason:

Accommodation refers to the eye’s ability to change the shape of the lens to focus on objects at different distances. Mydriatic eye drops primarily affect the muscles that control the pupil size, not the lens. While accommodation might be slightly affected due to the dilation, it is not the primary function impacted by mydriatics.

Choice B Reason:

Refraction is the bending of light as it passes through the lens of the eye to focus on the retina. Mydriatic eye drops do not directly affect the refractive properties of the eye. The primary purpose of these drops is to dilate the pupil, which does not significantly alter the eye’s refractive ability.

Choice C Reason:

Eye convergence is the simultaneous inward movement of both eyes toward each other to maintain single binocular vision when viewing an object. Mydriatic eye drops do not directly interfere with the muscles responsible for eye convergence. Therefore, this function remains largely unaffected during the therapeutic period.

Choice D Reason:

Pupillary constriction is the narrowing of the pupil, which is controlled by the sphincter pupillae muscle. Mydriatic eye drops cause the pupil to dilate by relaxing this muscle, thereby preventing pupillary constriction. This is the primary function that will not respond during the therapeutic period after administration of mydriatic eye drops.

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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 client has a prescription for heparin 5000 units IV STAT. Several pre-filled syringes of low molecular weight heparin are available in the client’s medication drawer. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is assessing the eyes of a client who just received mydriatic eye drops. Which physiological function of the eye will not respond during the therapeutic period after administration of the eye drops?

Correct Answer is D

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.