The client is receiving IV doses of Vancomycin every 12 hours. Which would be the nurse's priority to monitor for complications during the period that the patient is receiving this drug?

Serum potassium (K) and sodium (Na) levels.

Temperature and blood pressure.

Daily weight and edema.

Serum creatinine (Cr) and blood urea nitrogen (BUN) levels.

Answer and Explanation

The Correct Answer is D

Choice A reason: Monitoring serum potassium and sodium levels is important in many clinical situations, but it is not the primary concern when administering Vancomycin. Vancomycin can cause nephrotoxicity, which is best assessed by monitoring kidney function indicators such as serum creatinine and blood urea nitrogen levels.

Choice B reason: Temperature and blood pressure should be monitored regularly in patients receiving IV medications, especially antibiotics, to detect signs of infection or adverse reactions. However, the specific priority when administering Vancomycin is monitoring for nephrotoxicity, which is more accurately assessed through serum creatinine and BUN levels.

Choice C reason: Daily weight and edema monitoring are important for assessing fluid balance and potential heart or kidney issues. While useful, these are not the primary markers for detecting complications related to Vancomycin administration.

Choice D reason: Serum creatinine and blood urea nitrogen levels are critical indicators of kidney function. Vancomycin can cause nephrotoxicity, so monitoring these levels helps detect any signs of kidney injury early, ensuring appropriate adjustments to the medication regimen to prevent further damage.

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Correct Answer is B

Explanation

Choice A reason: An increased heart rate is not an expected therapeutic response to adenosine. Adenosine is used to slow the heart rate by temporarily blocking the electrical conduction through the atrioventricular (AV) node. This action is crucial in managing supraventricular tachycardia (SVT), as it can help restore a normal heart rhythm. An increased heart rate would suggest that the medication is not working as intended, and the underlying tachycardia may persist or worsen.

Choice B reason: A short period of asystole is the correct and expected therapeutic response when administering adenosine. Adenosine works by briefly stopping the heart's electrical activity, leading to a brief asystole (lack of heartbeat). This allows the heart's natural pacemaker to reset and potentially restore a normal rhythm. Although this can be alarming, it is a known and anticipated effect of the drug, and it typically resolves quickly as the heart resumes normal activity.

Choice C reason: Hypertension is not an expected response to adenosine. Adenosine generally causes vasodilation, which can lower blood pressure. The primary focus of adenosine in the context of SVT is on its cardiac effects rather than influencing blood pressure significantly. If hypertension occurs, it may be unrelated to the administration of adenosine and could indicate another underlying issue that needs to be addressed.

Choice D reason: Decreased intraocular pressure is not a relevant or expected response to adenosine administration in the context of managing SVT. Adenosine's primary effect is on the heart's electrical conduction system, and it does not significantly impact intraocular pressure. The focus should remain on observing the cardiac responses to ensure the medication is effectively managing the SVT.

A. Respiratory compromise. B. Stress ulcer. C. Paralytic ileus. D. Spinal shock.

Correct Answer is A

Explanation

Choice A reason: Respiratory compromise is the greatest risk for a client with a C4 spinal cord injury. The C4 spinal level is critical for the function of the diaphragm, which is the main muscle responsible for breathing. Injury at this level can impair diaphragmatic function, leading to difficulty in breathing or even respiratory failure. Immediate and continuous monitoring of respiratory status is essential for these patients to ensure adequate ventilation and oxygenation.

Choice B reason: Stress ulcers can develop in patients with spinal cord injuries due to the stress response and immobility. However, they are not the highest immediate risk compared to respiratory compromise, which can be life-threatening if not promptly addressed.

Choice C reason: Paralytic ileus, a condition where the intestines stop moving, can occur in spinal cord injury patients due to disruption of the nervous system control of the gut. While it is a significant concern, it is not as immediately life-threatening as respiratory compromise.

Choice D reason: Spinal shock is a condition that can occur after a spinal cord injury, leading to temporary loss of reflexes below the level of the injury. While it is an important condition to recognize and manage, the most urgent risk for a patient with a C4 injury is respiratory compromise due to the potential impact on breathing.

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The client is receiving IV doses of Vancomycin every 12 hours. Which would be the nurse's priority to monitor for complications during the period that the patient is receiving this drug?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse administers prescribed adenosine to a symptomatic patient in supraventricular tachycardia (SVT). Which response would the nurse assess for as an expected therapeutic response?

Correct Answer is B

Explanation

A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for?

Correct Answer is A

Explanation

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