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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Free Nursing Study Resources

Correct Answer is A

Explanation

A) Apply a pulse oximeter to the client per protocol: The priority intervention is to monitor the client’s respiratory status closely when initiating a continuous epidural infusion with an opioid analgesic. Opioids can cause respiratory depression, and using a pulse oximeter helps in detecting any drop in oxygen saturation, allowing for timely intervention if respiratory issues arise.

B) Insert an indwelling urinary catheter per protocol: While an indwelling urinary catheter might be used in some cases for convenience and monitoring, it is not the immediate priority in the context of starting an epidural opioid infusion. The primary concern is monitoring for respiratory depression and ensuring the client’s safety with the opioid medication.

C) Administer an antiemetic per PRN prescription: Administering an antiemetic may be necessary if the client experiences nausea, which is a potential side effect of opioids. However, the more immediate concern when starting an opioid infusion is ensuring the client’s respiratory function is stable.

D) Administer a stool softener per PRN protocol: Stool softeners might be required to manage opioid-induced constipation, but this is not the most urgent concern when starting the medication. The immediate priority is monitoring respiratory status to prevent potential complications associated with opioid use.

A. A quiet, restful environment. B. A dimly lit room. C. A warm room temperature. D. Cool, humidified air.

Correct Answer is B

Explanation

A. A quiet, restful environment:
While a quiet and restful environment may be beneficial for general comfort, it does not specifically address the visual issues related to the use of mydriatic medications. Mydriatics cause pupil dilation, which can increase sensitivity to light, so a dimly lit room is more appropriate for managing light sensitivity.

B. A dimly lit room:
A dimly lit room is best for a client receiving mydriatic medication because mydriatics cause pupil dilation, which can lead to increased sensitivity to light and difficulty with bright environments. Reducing light exposure helps manage these symptoms and improve comfort.

C. A warm room temperature:
While maintaining a comfortable room temperature is important, it does not specifically address the visual discomfort caused by mydriatic medications. The primary concern here is light sensitivity, which is better managed with dim lighting rather than room temperature.

D. Cool, humidified air:
Cool, humidified air can be helpful for certain respiratory conditions or comfort but does not directly address the issue of light sensitivity associated with mydriatic medication use. The focus should be on managing light exposure rather than air quality.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing intervention has priority when initiating a continuous epidural infusion with an opioid analgesic?

Correct Answer is A

Explanation

The nurse is planning the home care of a client who is receiving a mydriatic medication. Which environment is best for this client?

Correct Answer is B

Explanation

A client with benign prostatic hyperplasia receives a new prescription of tamsulosin. Which intervention should the nurse perform to monitor for an adverse reaction?

A client receives a prescription for penicillin 1.2 million units IM. The available vial is labeled, "600,000 units/2 mL." How many mL should the nurse administer? (Enter numeric value only.)

Which intervention is most important for the nurse to implement for a client with type 2 diabetes mellitus (DM) who is receiving insulin lispro?

To control asthma, a client in a residential treatment facility uses a fluticasone propionate and salmeterol discus inhalation system, which provides an inhaled powdered form of these combined medications. Which instruction should the nurse provide to this client's caregivers?

The nurse is reviewing the client's laboratory values. Which serum laboratory value indicates to the nurse that a prescription for atorvastatin is having the desired effect for a client at risk for coronary artery disease?

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?

A female client with a history of peptic ulcer disease receives a prescription for misoprostol. Which information provided by the client indicates to the nurse a need for further teaching?