Nokea
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: This question is identical to Question 30. Peak vancomycin levels are drawn 1 hour post-infusion, troughs 1 hour pre-dose (A). Other timings (B, C, D) miss accurate concentrations. Note: Duplicate question; consider removing.
You may also like to solve these questions
A client in the surgical recovery area asks the nurse to bring the largest possible dose of pain medication available. Which action should the nurse implement first?
- A. Determine when the last dose was administered.
- B. Review the history for past use of recreational drugs.
- C. Ask the client to rate the current level of pain using a pain scale.
- D. Encourage the client to use diversional thoughts to manage pain.
Correct Answer: C
Rationale: Assessing the client’s pain level using a pain scale (C) is the first step to quantify pain and guide appropriate dosing. Determining the last dose (A) and reviewing drug history (B) are secondary. Diversional thoughts (D) are a non-pharmacological adjunct, not the priority.
A female patient with multiple sclerosis reports less fatigue and improved memory since she started using the herbal supplement, ginkgo biloba. What is the most important information for the nurse to include in the teaching plan for this patient?
- A. Nausea and diarrhea can occur when using this supplement.
- B. Ginkgo biloba use should be limited and not taken during pregnancy.
- C. Aspirin and non-steroidal anti-inflammatory drugs interact with ginkgo.
- D. Anxiety and headaches increase with the use of ginkgo biloba.
Correct Answer: C
Rationale: This question is identical to Question 39. Ginkgo biloba’s interaction with aspirin/NSAIDs (C) increases bleeding risk, a critical teaching point. Other side effects (A, D) and pregnancy limits (B) are less urgent. Note: Duplicate question; consider removing.
A client with type I diabetes mellitus has been prescribed a glucagon emergency kit for home use. When should the nurse instruct the client and family to administer glucagon?
- A. Prior to meals to prevent hyperglycemia.
- B. When symptoms of severe hypoglycemia are present.
- C. When the client is unable to eat during sick days.
- D. At the onset of symptoms of diabetic ketoacidosis.
Correct Answer: B
Rationale: This question is identical to Question 25. Glucagon is for severe hypoglycemia (B), not hyperglycemia (A), sick days (C), or ketoacidosis (D). Note: Duplicate question; consider removing.
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.
A patient with nasal congestion has been prescribed phenylephrine 10 mg by mouth every 4 hours. What patient condition should the nurse report to the healthcare provider before administering the medication?
- A. Hypertension.
- B. Bronchitis.
- C. Diarrhea.
- D. Edema.
Correct Answer: A
Rationale: Phenylephrine, a decongestant, can raise blood pressure, making hypertension (A) a contraindication requiring provider consultation. Bronchitis (B), diarrhea (C), and edema (D) are not directly affected by phenylephrine.