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
After a femoral-popliteal bypass, the client should be placed in a supine position with the right leg extended and flat. This position helps to prevent kinking and occlusion of the graft, which could lead to complications such as graft thrombosis.
Choice B rationale
High-Fowler’s position with the right leg extended is not recommended. This position could put strain on the surgical site and potentially compromise the graft.
Choice C rationale
Supine with the right leg flexed at a 45-degree angle is not advised. Flexing the leg could lead to kinking of the graft and subsequent complications.
Choice D rationale
Semi-Fowler’s with the right leg on two pillows is not the optimal position. While elevation can help with swelling, excessive elevation could potentially compromise blood flow to the graft.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Rotating injection sites when administering insulin glargine is important to prevent lipodystrophy, a condition that can affect insulin absorption.
Choice B rationale
Insulin glargine has no peak of action, which reduces the risk of hypoglycemia. This is a key feature of long-acting insulins like glargine.
Choice C rationale
Food does not need to be consumed within 30 minutes after injection of insulin glargine. This is a characteristic of rapid-acting insulins, not long-acting insulins like glargine.
Choice D rationale
Checking for microalbuminuria if blood glucose levels are above 280 mg/dL is a good practice. Microalbuminuria can be an early sign of kidney damage, which can occur with poorly controlled diabetes.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.