The nurse checks the patient’s laboratory work prior to administering a dose of vancomycin and finds that the trough vancomycin level is 24 mcg/mL. What will the nurse do next?
Hold the drug, and administer 4 hours later.
Administer the vancomycin as ordered.
Hold the drug, and notify the prescriber.
Repeat the test to verify results.
The Correct Answer is C
Choice A rationale:
Holding the drug and administering it 4 hours later is not the appropriate action. The trough vancomycin level of 24 mcg/mL is higher than the recommended range of 10-20 mcg/mL, indicating potential risk for toxicity. Administering the drug later does not address the immediate concern of a high trough level.
Choice B rationale:
Administering the vancomycin as ordered is not the correct action in this case. The trough level is above the recommended range, which could lead to vancomycin toxicity. The nurse should not administer the medication without addressing the high trough level. Choice C rationale:
This is the correct action. The nurse should hold the drug and notify the prescriber because the trough vancomycin level is higher than the recommended range. The prescriber can then make a decision based on this information, which may include adjusting the dose, extending the dosing interval, or ordering additional tests.
Choice D rationale:
While repeating the test to verify results might be done eventually, it should not be the immediate next step. The nurse has a responsibility to ensure patient safety, and with a trough level above the recommended range, the priority is to prevent potential toxicity. Therefore, the nurse should hold the drug and notify the prescriber.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Let’s solve the medication math problem step by step:
Step 1: Identify the total daily dose of amoxicillin. The total daily dose is 2 gm/day.
Step 2: Convert the total daily dose from grams to milligrams, as the available medication is in milligrams. We know that 1 gm = 1000 mg, so 2 gm = 2000 mg.
Step 3: The total daily dose is divided into two doses. So, each dose will be 2000 mg ÷ 2 = 1000 mg.
Step 4: Determine the number of tablets for each dose. Each tablet contains 500 mg of amoxicillin. So, the number of tablets for each dose is 1000 mg ÷ 500 mg/tablet = 2 tablets.
So, the nurse should administer 2 tablets of amoxicillin with each dose.
Correct Answer is B
Explanation
Choice A rationale:
Shaking the insulin vial vigorously is not recommended. It can lead to the formation of bubbles, which can affect the accuracy of the dose. Instead, insulin vials should be gently rolled between the hands to mix.
Choice B rationale:
Injecting insulin into the abdominal area is indeed a recommended practice. The abdomen is a preferred site for insulin injection because it has a faster absorption rate compared to other areas. This can help to more effectively regulate blood glucose levels.
Choice C rationale:
Exercise typically lowers blood glucose levels, so insulin doses may need to be reduced to prevent hypoglycemia. Clients should monitor their blood glucose closely and adjust insulin as directed by their healthcare provider.
Choice D rationale:
Freezing unopened insulin vials is not advised. Freezing can disrupt the insulin structure, rendering it ineffective. Insulin should be stored in a refrigerator at a temperature between 2°C and 8°C (36°F and 46°F). Once opened, it can be kept at room temperature for up to 28 days.
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