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 C,D,A,B

Explanation

Choice A reason: Assessing the client's respiratory status is the top priority action. This ensures that any immediate issues with breathing or oxygenation are identified and managed promptly. Respiratory status can quickly deteriorate in patients with heart failure, and addressing this first can be life-saving.

Choice B reason: Drawing blood to assess the patient's serum electrolytes is important to determine any imbalances that need immediate correction. Electrolyte levels can affect heart function and overall stability, so understanding the patient's current status helps guide further treatment.

Choice C reason: Administering the prescribed intravenous furosemide (Lasix) is critical for managing fluid overload in heart failure. Furosemide helps reduce fluid retention and alleviate symptoms such as pulmonary edema, which can improve respiratory status and overall comfort.

Choice D reason: Asking the patient about an advanced directive is important for understanding their wishes and planning care accordingly. However, it is not an immediate priority compared to stabilizing the patient's respiratory status and addressing urgent medical needs.

A. Woman with a blood pressure of 158/90 mm Hg. B. Patient with Kussmaul respirations. C. Man with skin itching from head to toe. D. Patient with halitosis and stomatitis.

Correct Answer is B

Explanation

Choice A reason: A blood pressure of 158/90 mm Hg in a patient with chronic kidney disease (CKD) is elevated and requires management to prevent complications. However, it is not as immediately life-threatening as Kussmaul respirations, which indicate severe metabolic acidosis.

Choice B reason: The patient with Kussmaul respirations should be assessed first. Kussmaul respirations are deep, labored breathing patterns typically associated with severe metabolic acidosis, such as diabetic ketoacidosis (DKA) or severe kidney failure. This condition requires immediate intervention to correct the underlying acidosis and stabilize the patient's condition.

Choice C reason: Itching (pruritus) is a common symptom in CKD due to the accumulation of uremic toxins. While it can be very uncomfortable and requires treatment, it is not as urgent as Kussmaul respirations, which indicate a potentially life-threatening situation.

Choice D reason: Halitosis (bad breath) and stomatitis (inflammation of the mouth) can occur in CKD due to the buildup of uremic toxins and other factors. These symptoms need attention, but they do not indicate an immediate threat to the patient's life compared to Kussmaul respirations.

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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 admits a patient who is experiencing an exacerbation of heart failure. Drag and drop in order of priority actions.

Correct Answer is C,D,A,B

Explanation

Correct Answer is B

Explanation

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