The patient is a 75-year-old female who has been admitted to the preoperative area in preparation for pacemaker insertion.

She reports that she is undergoing this procedure because her heart rate has been consistently low, she feels constantly fatigued, and she has experienced one episode of fainting due to a low heart rate.

The patient has a history of progressively worsening symptomatic bradycardia and a history of atrial fibrillation, which is controlled by medication.

She has been off anticoagulants for four days in preparation for the procedure.

As the nurse prepares the patient’s plan of care, which four findings would indicate that it would be safe to administer the antibiotic vancomycin?

Potassium level is 4.4 mEq/L (4.4 mmol/L).

The antibiotic is being used for prophylaxis.

Blood urea nitrogen level is 17 mg/dL (6.07 mmol/L).

The dosage of the antibiotic is within the safe range.

The patient has no known allergies.

The patient has a peripheral IV in a large vein.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A rationale
A potassium level of 4.4 mEq/L (4.4 mmol/L) is within the normal range. Potassium is a critical electrolyte in the body, playing key roles in cellular metabolism, protein synthesis, and electrical action potential regulation across cell membranes. Normal potassium levels typically range from 3.5 to 5.1 mmol/L1. Therefore, a potassium level of 4.4 mEq/L indicates that the patient’s potassium level is within the normal range, which is a safe condition for the administration of vancomycin.
Choice B rationale

The use of antibiotics for prophylaxis, or prevention, is a common practice in healthcare, particularly in surgical procedures such as pacemaker insertion. This is done to prevent potential infections that could occur during or after the procedure. Vancomycin is a type of antibiotic that is often used for prophylaxis against infections caused by gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA)3. Therefore, if the antibiotic is being used for prophylaxis, it would be safe to administer vancomycin.
Choice C rationale
A blood urea nitrogen (BUN) level of 17 mg/dL (6.07 mmol/L) is within the normal range. The BUN test measures the amount of urea nitrogen in the blood, which can provide important information about kidney function. Urea nitrogen is a waste product that is created in the liver when protein is metabolized. It is then transported through the blood to the kidneys, which filter out most of the urea nitrogen, leaving a small amount in the blood. Normal BUN levels typically range from 6 to 20 mg/dL4. Therefore, a BUN level of 17 mg/dL indicates that the patient’s kidney function is within the normal range, which is a safe condition for the administration of vancomycin.
Choice E rationale
The absence of known allergies in a patient is a crucial factor in determining the safety of administering any medication, including vancomycin. Allergic reactions to medications can range from mild symptoms such as rash and itching to severe and life-threatening conditions such as anaphylaxis. Therefore, if a patient has no known allergies, it would be safe to administer vancomycin.
Choice D rationale

While it’s true that the dosage of the antibiotic should be within the safe range, the specific dosage of vancomycin for the patient isn’t provided in the question. Therefore, we cannot definitively say that this condition is met based on the information given.
Choice F rationale
Although vancomycin can be administered via a peripheral IV in a large vein, it’s important to note that vancomycin has a low pH and may cause venous irritation and tissue damage in cases of extravasation. Therefore, while it’s possible to administer vancomycin this way, it’s not necessarily an indicator of safety.

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Correct Answer is D

Explanation

Choice A rationale
While switching to less anxiety-provoking questions might help in some situations, it does not address the immediate issue of the client undressing inappropriately.
Choice B rationale
Ignoring the client’s inappropriate behavior could potentially encourage further inappropriate actions and does not respect the therapeutic boundaries necessary in a nurse-client relationship.
Choice C rationale
Leaving the client’s room might escalate the situation further and does not address the immediate issue.
Choice D rationale
The nurse should assertively but respectfully communicate that undressing is not appropriate during the interview. This sets clear boundaries and expectations for the client’s behavior.

A. Use a cushion when sitting. B. Offer a high protein diet. C. Provide only distilled water. D. Document abdominal girth.

Correct Answer is D

Explanation

Choice A rationale
Using a cushion when sitting can provide comfort but does not directly address the client’s electrolyte imbalance, elevated blood pressure, or weight gain.
Choice B rationale

Offering a high protein diet can be beneficial for clients with hepatic failure to support liver regeneration and prevent malnutrition. However, it does not directly address the client’s immediate issues.
Choice C rationale
Providing only distilled water does not address the client’s electrolyte imbalance, elevated blood pressure, or weight gain. In fact, it could potentially exacerbate electrolyte imbalances.
Choice D rationale
Documenting abdominal girth can help monitor for fluid accumulation (ascites), a common complication of hepatic failure that can contribute to weight gain and elevated blood pressure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While conducting an admission assessment of a female client with bipolar disorder, the client suddenly starts to undress and throw her clothes around the room. What should be the nurse’s initial action?

Correct Answer is D

Explanation

A client with hepatic failure has an electrolyte imbalance, elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours. What intervention should the nurse include in the plan of care?

Correct Answer is D

Explanation

A male adult is admitted due to an overdose of acetaminophen. After being transferred to the mental health unit, the patient is informed that he has liver damage. What is the most crucial information for the nurse to include in the patient’s discharge plan?

What intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

The nurse inspects the airway and finds no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

A client with influenza requires assistance in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. What action should the nurse take?

A 10-year-old child with pneumonia is receiving oxygen at 5 L/minute via a nasal cannula. When planning care for this child, what principle of oxygen administration should the nurse keep in mind?