The nurse is administering intravenous vancomycin to a client who has had gastrointestinal surgery. Which nursing measures are appropriate? (Select all that apply.)
Restricting fluids while the client is on this medication
Administer the drug over at least 60 minutes
Reporting a trough drug level of24 mcg/mL and holding the drug
Monitoring serum creatinine levels
Instructing the client to report dizziness or a feeling of fullness in the ears
Correct Answer : B,C,D,E
A. vancomycin can be nephrotoxic and fluid restriction is inappropriate
B. Slow infusion of vancomycin is key to avoid flush reactions
C. Normal trough levels for vancomycin are 10-20mcg/ml- 24mcg/ml increases risk of toxicity
D. Monitoring serum creatinine monitors for renal damage
E. Vancomycin can cause hearing loss and clients should be advised any early signs of ototoxicity such as ear fullness
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
vasodilators can cause hypotension due to reduced peripheral vascular resistance predisposing them to dizziness and falls
The other options are unrelated to vasodilators
Correct Answer is ["B","C","D","E"]
Explanation
Vancomycin is nephrotoxic and ototoxic and any ear fullness and rising serum creatinine levels should be reported. It also has a narrow therapeutic levels of 10-20mcg/ml and levels above that should be reported. The drug should be administered over 60 mins to prevent red man syndrome
A- Being nephrotoxic, restricting fluid intake could increase risk of renal damage
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