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 B
Explanation
Choice A rationale
Increasing the nighttime insulin glargine dose may exacerbate the Somogyi effect, a phenomenon where the blood sugar level drops too low overnight, causing a rebound high blood sugar level in the morning.
Choice B rationale
Consuming a snack at bedtime can help prevent the blood sugar level from dropping too low overnight, thus preventing the Somogyi effect.
Choice C rationale
Checking the morning cortisol level is not directly related to managing the Somogyi effect.
Choice D rationale
Checking the glucose level at 2 a.m. and 8 a.m. can help identify the Somogyi effect, but it does not prevent it.
Correct Answer is C
Explanation
Choice A rationale
Omitted meals can lead to hypoglycemia, not diabetic ketoacidosis (DKA). DKA is caused by a lack of insulin, not a lack of food intake.
Choice B rationale
Polydipsia and polyphagia are symptoms of hyperglycemia, not causes of DKA. They occur as the body tries to compensate for high blood sugar levels.
Choice C rationale
Not taking enough insulin is a primary cause of the development of DKA. Without enough insulin, the body begins to break down fat for fuel, which produces acids known as ketones.
Choice D rationale
An insulin overdose would lead to hypoglycemia, not DKA. DKA is caused by a lack of insulin, not an excess.
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