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A client is receiving intravenous vancomycin, and the nurse plans to draw blood for a peak and trough to determine the serum level of the drug. Which collection times would provide the best determination of these levels?
- A. One hour after completion of the IV dose and one hour before the next administration of the medication.
- B. Two hours after completion of the IV dose and two hours before the next administration of the medication.
- C. Thirty minutes into the administration of the IV dose and 30 minutes before the next administration of the medication.
- D. Immediately after completion of the IV dose and 30 minutes before the next administration of the medication.
Correct Answer: A
Rationale: Vancomycin peak levels are drawn 1 hour post-infusion, and trough levels 1 hour pre-dose (A) for accurate therapeutic monitoring. Two-hour intervals (B) miss peak/trough. Mid-infusion (C) is too early for peak. Immediate post-dose (D) underestimates peak.
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After taking orlistat for one week, a female patient tells the home health nurse that she is experiencing increasingly frequent oily stools and gas. What action should the nurse take?
- A. Ask the patient to describe her dietary intake history for the last several days.
- B. Advise the patient to stop taking the drug and contact her healthcare provider.
- C. Instruct the patient to increase her intake of saturated fats over the next week.
- D. Obtain a stool specimen to evaluate for occult blood and fat content.
Correct Answer: A
Rationale: Orlistat inhibits fat absorption, causing oily stools and gas if dietary fat is high. Assessing dietary intake (A) identifies the cause. Stopping the drug (B) is premature. Increasing fats (C) worsens symptoms. Stool testing (D) is unnecessary for known side effects.
The nurse is administering the muscle relaxant baclofen orally to a patient diagnosed with multiple sclerosis. What intervention should the nurse implement?
- A. Advise the patient to move slowly and cautiously when getting up and walking.
- B. Evaluate the patient’s muscle strength every 4 hours.
- C. Monitor the patient’s intake and output every 8 hours.
- D. Ensure the patient understands to stop taking baclofen before using other antispasmodics.
Correct Answer: A
Rationale: Baclofen causes drowsiness and weakness, increasing fall risk. Advising slow, cautious movement (A) enhances safety. Muscle strength checks (B) and intake/output (C) are less critical. Abruptly stopping baclofen (D) risks withdrawal (e.g., seizures), not advised.
A client has been prescribed ciprofloxacin 400 mg intravenously (IV) every 12 hours to be infused over an hour. The IV bag contains ciprofloxacin 400 mg in dextrose 5% in water (D5W) 200 mL. How many mL/hour should the nurse program the infusion pump to deliver? (Enter numerical value only.)
Correct Answer: 200
Rationale: Infusion rate: 200 mL / 1 hr = 200 mL/hr. The pump should be set to deliver 200 mL/hr to administer ciprofloxacin correctly.
A client with Parkinson’s disease who is taking carbidopa/levodopa reports that the urine appears to be darker in color. What action should the nurse take?
- A. Encourage an increase in oral intake.
- B. Explain that the color change is normal.
- C. Obtain a specimen for a urine culture.
- D. Measure the client’s urinary output.
Correct Answer: B
Rationale: Carbidopa/levodopa can darken urine (B), a benign side effect. Increased fluids (A) or urine culture (C) are unnecessary unless other symptoms arise. Measuring output (D) doesn’t address the color change.
The nurse administers naloxone to a patient with opioid-induced respiratory depression. An hour later, the nurse finds the patient has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unresponsive. What action should the nurse take?
- A. Administer a second dose of naloxone.
- B. Prepare to assist with chest tube insertion.
- C. Determine Glasgow Coma Scale score.
- D. Initiate cardiopulmonary resuscitation (CPR).
Correct Answer: D
Rationale: Severe respiratory depression (4 breaths/min), hypoxia (75% SpO₂), and unresponsiveness require immediate CPR (D) to restore circulation/oxygenation. A second naloxone dose (A) may be needed but is secondary. Chest tubes (B) are irrelevant. Glasgow scoring (C) delays critical intervention.