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

Answer and Explanation

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

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Correct Answer is C

Explanation

Choice A rationale

Reddish feet when put down could be a sign of dependent rubor, a condition that occurs due to peripheral arterial disease (PAD). When the legs are in a dependent (downward) position, gravity aids in delivering blood to the area, causing a reddish color. However, this is a common symptom of PAD and does not require immediate intervention.

Choice B rationale

Loss of hair on the feet and legs is another symptom of PAD1. This happens because inadequate blood flow deprives the hair follicles of the nutrients they need to grow. While this symptom indicates worsening PAD, it does not warrant immediate intervention.

Choice C rationale

Applying a heating pad to cold legs could lead to burns because PAD can cause loss of sensation in the legs. This warrants immediate intervention to prevent injury.

Choice D rationale

Leg pain during walking, also known as claudication, is a common symptom of PAD1. This happens because the muscles are not getting enough oxygen due to reduced blood flow.

However, this symptom does not require immediate intervention but should be evaluated further.

A. Infectious agent and reservoir. B. Mode of transmission and portal of entry. C. Susceptible host and infectious agent. D. Portal of exit and mode of transmission.

Correct Answer is D

Explanation

Choice A rationale

The infectious agent is the pathogen that causes the disease, and the reservoir is where the infectious agent lives and multiplies. Hand washing does not directly intervene between these two links.

Choice B rationale

The mode of transmission is how the infectious agent travels to other people and places, and the portal of entry is the route by which an infectious agent enters a new host. Hand washing does not directly intervene between these two links.

Choice C rationale

The susceptible host is a person who is vulnerable to the disease, and the infectious agent is the pathogen that causes the disease. Hand washing does not directly intervene between these two links.

Choice D rationale

The portal of exit is the route by which an infectious agent escapes or leaves the reservoir, and the mode of transmission is how the infectious agent travels to other people and places. Hand washing directly intervenes between these two links by removing the infectious agent from the hands (portal of exit) and preventing its transmission to other people or surfaces.

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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)

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Choice E rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with a diagnosis of chronic peripheral arterial disease. Which statement by the patient warrants immediate intervention by the nurse?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is teaching a patient to wash their hands after using the bathroom as an attempt to break the chain of infection. Between which two links in the chain of infection does this action intervene?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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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)