The client is a 75-year-old female admitted to the preoperative area to prepare for pacemaker insertion. Client reports she is having this done because her heart rate has been staying very low, she is always tired, and she has passed out once from low heart rate. Client has history of worsening symptomatic bradycardia. History of atrial fibrillation controlled. 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

Peripheral IV in large vein

Potassium 4.4 mEq/L (4.4 mmol/L)

Used for prophylaxis

Blood urea nitrogen 17 mg/dL (6.07 mmol/L)

Dosage in safe range

Answer and Explanation

Correct Answer : A,B,D,F

A. No known allergies:
Having no known allergies is a significant factor in determining the safety of administering vancomycin, as it reduces the risk of an allergic reaction. Vancomycin can cause allergic reactions or hypersensitivity, so it’s important to ensure the client is not allergic to this medication.

B. Peripheral IV in large vein:
Vancomycin should be administered through a large vein because it can be irritating to smaller veins and potentially cause thrombophlebitis or vein damage. Using a large vein helps to minimize these risks and ensure safe administration.

C. Potassium 4.4 mEq/L (4.4 mmol/L):
While potassium levels are important to monitor, they are not directly related to the safety of administering vancomycin. Vancomycin does not have a direct impact on potassium levels, so this finding does not specifically indicate the safety of vancomycin administration.

D. Used for prophylaxis:
Vancomycin is often used as prophylaxis in certain surgical procedures to prevent infection, especially in cases where there is a high risk of methicillin-resistant Staphylococcus aureus (MRSA) infection. The use of vancomycin for prophylaxis is a common practice and indicates it is being administered for an appropriate reason.

E. Blood urea nitrogen 17 mg/dL (6.07 mmol/L):
A blood urea nitrogen (BUN) level of 17 mg/dL is slightly elevated but not necessarily a contraindication for vancomycin administration. However, vancomycin can impact kidney function, so it is important to monitor renal function but not the sole factor in determining safety.

F. Dosage in safe range:
Ensuring the dosage of vancomycin is within the safe range is crucial for preventing toxicity and achieving therapeutic efficacy. This is an essential consideration when administering the medication to avoid adverse effects and ensure effective treatment.

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Correct Answer is A

Explanation

A. When signs of severe hypoglycemia occur:
Glucagon is used to rapidly increase blood glucose levels in cases of severe hypoglycemia when the person is unable to eat or drink. It is administered in emergency situations where the individual is unconscious or unable to consume oral glucose.

B. Before meals to prevent hyperglycemia:
Glucagon is not used to prevent hyperglycemia or as a routine preventive measure. It is specifically for emergency treatment of severe hypoglycemia.

C. When unable to eat during sick days:
While glucagon can be used if the person is unable to eat due to severe hypoglycemia, it is not typically used as a preventative measure for situations where the client is simply unable to eat. Regular monitoring and management of blood glucose levels are necessary during illness.

D. At the onset of signs of diabetic ketoacidosis:
Glucagon is not used to treat diabetic ketoacidosis (DKA). DKA is managed with insulin, fluids, and electrolytes, not glucagon.

A. Avoid taking the medication on an empty stomach. B. Keep medication fliers for frequent review and reference. C. Maintain a fluid intake of 1500 to 3000 mL per day. D. Report fluctuations in weight to the healthcare provider.

Correct Answer is C

Explanation

A. Avoid taking the medication on an empty stomach:
While it can be helpful to take lithium with food to minimize gastrointestinal upset, it is not the primary instruction for lithium use. The most important aspect of lithium therapy involves fluid balance and monitoring.

B. Keep medication fliers for frequent review and reference:
While reviewing medication information is useful, it is not as critical as maintaining appropriate fluid intake and monitoring for side effects specific to lithium.

C. Maintain a fluid intake of 1500 to 3000 mL per day:
This is crucial because lithium levels can be affected by changes in fluid balance. Inadequate fluid intake can lead to dehydration, which can increase lithium levels and the risk of toxicity. Therefore, maintaining adequate hydration is essential for safe lithium use.

D. Report fluctuations in weight to the healthcare provider:
While fluctuations in weight can be relevant for overall health monitoring, the more immediate concern with lithium therapy is to maintain proper fluid intake and monitor for signs of toxicity or dehydration.

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Naxlex Comprehensive Predictor Exams

A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client and family that glucagon needs to be administered?

Correct Answer is A

Explanation

The nurse is providing medication teaching to a client with bipolar disorder who receives a prescription for lithium carbonate. Which instruction should the nurse emphasize with the client?

Correct Answer is C

Explanation

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