The client has been receiving vancomycin 1 gram IV every 12 hours for 2 days.
What nursing actions are appropriate when administering this medication? (Select all that apply)
Assess for Red Man Syndrome
Assess the client’s hearing
Obtain an arterial blood gas (ABG)
Infuse the drug over 1-2 hours
Obtain an ordered trough level prior to next scheduled dose
Correct Answer : A,B,D,E
Choice A rationale
Assess for Red Man Syndrome. Vancomycin can cause a reaction known as Red Man Syndrome, which is characterized by flushing and/or an erythematous rash that affects the face, neck, and upper torso. This is not an allergic reaction, but rather a direct histamine-release effect of the drug.
Choice B rationale
Assess the client’s hearing. Ototoxicity, which can manifest as hearing loss, is a potential side effect of vancomycin. Therefore, it’s important to monitor the client’s hearing during treatment.
Choice C rationale
Obtain an arterial blood gas (ABG). This is not typically required when administering vancomycin. ABGs are usually drawn to assess a patient’s acid-base balance and oxygenation status, not as a routine part of vancomycin administration.
Choice D rationale
Infuse the drug over 1-2 hours. Vancomycin should be administered over at least 60 minutes to avoid skin irritation. Infusing the drug too quickly can also increase the risk of Red Man Syndrome.
Choice E rationale
Obtain an ordered trough level prior to next scheduled dose. Monitoring vancomycin trough levels is important to ensure therapeutic efficacy and to avoid toxicity. Trough levels are typically drawn just before the next dose is due.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
When a patient is informed about a serious diagnosis like breast cancer and the need for a mastectomy, it is common for them to experience a range of emotions, including sadness, fear, and anxiety. As a nurse, providing emotional support and creating a safe space for the patient to express their feelings is crucial. Offering to be there for the patient if they want to talk acknowledges their emotional distress and provides comfort.
Choice B rationale
Asking the patient why they are upset may come across as insensitive or dismissive. The patient has just received a life-changing diagnosis, and their emotional reaction is completely normal and expected. It’s important to provide support and empathy rather than questioning their feelings.
Choice C rationale
Telling the patient that everything will be alright and there is no need to cry may seem comforting, but it can actually invalidate the patient’s feelings. It’s important to acknowledge the patient’s emotions and allow them to express their feelings without judgment.
Choice D rationale
Telling the patient that they will recover may be seen as providing false reassurance. While it’s important to maintain hope, it’s also crucial to be honest and realistic with the patient about their diagnosis and treatment.
Correct Answer is D
Explanation
Choice D rationale
The symptoms described - edema, severe pain, paresthesia, and tightness of the operative limb
- are indicative of Compartment Syndrome. This is a serious condition that can occur after surgery, where increased pressure within one of the body’s compartments results in insufficient blood supply to the area. It requires immediate treatment to prevent permanent damage.
Choice A rationale
While wound infection is a possible post-operative complication, it would typically present with symptoms such as redness, increased pain at the wound site, purulent discharge, and possibly fever. The symptoms described do not specifically indicate a wound infection.
Choice B rationale
Internal bleeding could cause pain and swelling, but it would likely also present with signs of shock, such as low blood pressure, increased heart rate, and altered mental status. The symptoms provided do not clearly indicate internal bleeding.
Choice C rationale
Graft rupture is a serious complication that could potentially cause severe pain and swelling. However, it would also likely cause significant hemodynamic instability, including hypotension and tachycardia. The symptoms described are more indicative of Compartment Syndrome.
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