Nokea
A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?
- A. I can start the medication 30 minutes earlier.
- B. I can adjust the time and schedule for when its convenient for you.
- C. I can infuse the medication at a faster rate.
- D. I have up to 2 hours after the usual schedule time to give you this medication.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Vancomycin is typically given at specific intervals to maintain therapeutic levels in the bloodstream.
2. Giving the medication 2 hours earlier may lead to suboptimal drug levels.
3. Answer D allows flexibility within the recommended dosing schedule.
4. Answers A, B, and C compromise the effectiveness and safety of vancomycin administration.
5. Option D ensures the medication is given within an appropriate timeframe.
You may also like to solve these questions
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
- A. Crackles in the lungs
- B. Increased abdominal girth
- C. Pink frothy sputum
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to efficiently pump blood to the lungs for oxygenation, leading to fluid backup in the systemic circulation. This results in fluid retention, particularly in the abdomen, causing increased abdominal girth. Crackles in the lungs (choice A) are indicative of left-sided heart failure. Pink frothy sputum (choice C) is a sign of pulmonary edema, which is a manifestation of left-sided heart failure. Hypertension (choice D) is not typically associated with right-sided heart failure.
A nurse is planning care for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?
- A. Standard precautions
- B. Airborne precautions
- C. Contact precautions
- D. Droplet precautions
Correct Answer: B
Rationale: The correct answer is B: Airborne precautions. Tuberculosis is spread through the air via droplet nuclei. Implementing airborne precautions involves placing the client in a negative pressure room, using an N95 respirator, and ensuring proper ventilation. Standard precautions (A) are used for all clients. Contact precautions (C) are used for clients with infections that can be spread by direct or indirect contact. Droplet precautions (D) are used for infections spread through larger respiratory droplets. In this case, airborne precautions are specifically needed due to the mode of transmission of tuberculosis.
A nurse is assessing a client who has a new diagnosis of diabetes mellitus. The nurse should identify that which of the following findings is a manifestation of hyperglycemia?
- A. Sweating
- B. Increased thirst
- C. Shakiness
- D. Decreased urination
Correct Answer: B
Rationale: Correct Answer: B - Increased thirst
Rationale: Hyperglycemia results in elevated blood glucose levels, which leads to osmotic diuresis and fluid loss, causing increased thirst. Sweating (A) is more commonly associated with hypoglycemia. Shakiness (C) is a symptom of hypoglycemia due to low blood sugar levels. Decreased urination (D) is not a typical manifestation of hyperglycemia as it is more commonly associated with conditions like dehydration or kidney issues.
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushings triad?
- A. Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg
- B. Decrease in heart rate to 120 bpm
- C. Rapid shallow respirations
- D. Hypotension
Correct Answer: A
Rationale: The correct answer is A: Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg. Cushing's triad is a classic sign of increased intracranial pressure (ICP), seen in traumatic brain injury. It consists of hypertension (elevated blood pressure), bradycardia (not tachycardia), and irregular respirations (not rapid shallow respirations). The increase in blood pressure is due to the body's attempt to maintain cerebral perfusion in response to the increased ICP. The other choices are incorrect because they do not align with the classic presentation of Cushing's triad in traumatic brain injury.
A nurse is caring for a client who has end-stage kidney disease. The clients adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the childs medical history should the nurse identify as a contraindication to the procedure?
- A. Amputation
- B. Osteoarthritis
- C. Hypertension
- D. Primary glaucoma
Correct Answer: C
Rationale: The correct answer is C: Hypertension. Hypertension is a contraindication for kidney donation due to the increased risk of kidney disease and complications post-donation. High blood pressure can impair kidney function and increase the risk of cardiovascular events. Amputation (A), osteoarthritis (B), and primary glaucoma (D) are not contraindications for kidney donation as they do not directly impact kidney function or pose significant risks for the donor.