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?

Choice A reason: Administering 2 tablets of digoxin 0.125 mg would provide the correct dosage of 0.25 mg. However, given the client's heart rate of 54/min, administering the medication could further lower the heart rate, which can be dangerous. The nurse should withhold the medication and notify the physician.

Choice B reason: Withholding the digoxin dose for decreased heart rate is the correct action. Digoxin is used to slow down the heart rate and strengthen heart contractions. A heart rate of 54/min is considered bradycardia (slow heart rate), and administering digoxin could exacerbate the bradycardia, leading to potential complications such as heart block or severe arrhythmias. Therefore, it is critical to withhold the medication and inform the physician of the client's current heart rate.

Choice C reason: Administering one tablet of digoxin 0.125 mg would not provide the full prescribed dose of 0.25 mg. More importantly, the client's low heart rate makes it unsafe to administer any dose of digoxin at this time.

Choice D reason: Withholding the digoxin dose for elevated blood pressure is not appropriate. Although the client has elevated blood pressure (144/96), the more immediate concern is the low heart rate. Digoxin affects heart rate more than blood pressure, and the risk of exacerbating bradycardia takes precedence.

Choice A reason: An epidural hematoma is a type of traumatic brain injury where blood accumulates between the dura mater and the skull. While it can cause severe symptoms, including headache, loss of consciousness, and neurological deficits, it does not typically present with ecchymosis behind the ears (Battle's sign) or bleeding from the ears. These signs are more indicative of a basilar skull fracture.

Choice B reason: An ischemic stroke occurs when a blood clot blocks or narrows an artery leading to the brain, causing reduced blood flow and oxygen to the brain tissue. Symptoms of an ischemic stroke include sudden weakness, numbness, difficulty speaking, and vision problems. However, it does not cause ecchymosis behind the ears or bleeding from the ears, which are specific signs of a basilar skull fracture.

Choice C reason: A subarachnoid hemorrhage is bleeding into the space between the brain and the tissue covering the brain (subarachnoid space). It often presents with a sudden, severe headache, nausea, vomiting, and loss of consciousness. While it is a serious condition, it does not typically cause ecchymosis behind the ears or bleeding from the ears.

Choice D reason: A basilar skull fracture is

The correct answer. This type of fracture involves the base of the skull and can cause characteristic signs such as ecchymosis behind the ears (Battle's sign) and bleeding from the ears due to the proximity of the fracture to the auditory canal and other structures. These symptoms are key indicators of a basilar skull fracture and require immediate medical attention.