Nokea
The nurse is preparing to administer the fourth dose of IV vancomycin to a client. Which set of laboratory values would alert the nurse to hold the vancomycin and notify the health care provider?
- A. Vancomycin trough 10 mg/L (6.9 umol/L), creatinine 1.1 mg/dL (97.2 umol/L), BUN 6 mg/dL (2.1 mmol/L)
- B. Vancomycin trough 14 mg/L (9.7 umol/L), creatinine 1.2 mg/dL (106.1 umol/L), BUN 10 mg/dL (3.6 mmol/L)
- C. Vancomycin trough 18 mg/L (12.4 umol/L), creatinine 0.6 mg/dL (53 umol/L), BUN 18 mg/dL (6.4 mmol/L)
- D. Vancomycin trough 23 mg/L (15.9 umol/L), creatinine 1.5 mg/dL (132.6 umol/L), BUN 24 mg/dL (8.6 mmol/L)
Correct Answer: D
Rationale: A vancomycin trough of 23 mg/L is above the therapeutic range (10-20 mg/L), indicating potential toxicity. Elevated creatinine (1.5 mg/dL) suggests renal impairment, which increases the risk of vancomycin accumulation and nephrotoxicity.
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A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV. What is the nurse's priority action?
- A. Assess the condition of the IV site
- B. Check 2 client identifiers before administering medications
- C. Consult a medication guide for compatibility
- D. Wash hands prior to administering medications
Correct Answer: C
Rationale: Ensuring medication compatibility prevents chemical interactions or precipitation in the IV line, which could harm the client or obstruct the catheter.
The nurse is providing postpartum teaching for a non-nursing mother. Which of the client's statements indicates the need for additional teaching?
- A. I'm wearing a support bra.
- B. I'm expressing milk from my breast.
- C. I'm drinking four glasses of fluid during a 24-hour period
- D. While I'm in the shower, I'll keep the water from running over my breasts
Correct Answer: B
Rationale: Non-nursing mothers should avoid expressing milk, as it stimulates further production. Support bras, adequate fluids, and avoiding breast stimulation are correct practices.
During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
- A. Syphilis
- B. Herpes
- C. Gonorrhea
- D. Condylomata
Correct Answer: B
Rationale: A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. Gonorrhea does not present as a lesion but is exhibited by a yellow discharge, so answer C is incorrect. Condylomata lesions are painless warts, so answer D is incorrect.
A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?
- A. With acceptance and views the victim's comment as an indication that their marriage is in trouble
- B. With fear of rejection causing increased rage toward the victim
- C. With a new commitment to seek counseling to assist with their marital problems
- D. With relief, and welcomes the separation as a means to have some personal time
Correct Answer: B
Rationale: With fear of rejection causing increased rage toward the victim. Fear of abandonment often escalates abusive behavior.
A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention?
- A. UAP has attached a bed alarm to the client's gown and bed
- B. UAP has been making hourly rounds on the client
- C. UAP has lowered the bed and raised all 4 side rails
- D. UAP has placed a fall risk ID bracelet on the client's wrist
Correct Answer: C
Rationale: Raising all four side rails is a restraint and can increase fall risk if the client attempts to climb over them. It also violates standards of care unless specifically prescribed.