Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The client has been receiving vancomycin 1 gram IV every 12 hours for 2 days.
What nursing actions are appropriate when administering this medication? (Select all that apply)
A. Assess for Red Man Syndrome
Assess for Red Man Syndrome. Vancomycin can cause a reaction known as Red Man Syndrome, which is characterized by flushing and/or an erythematous rash that affects the face, neck, and upper torso. This is not an allergic reaction, but rather a direct histamine-release effect of the drug.
B. Assess the client’s hearing
Assess the client’s hearing. Ototoxicity, which can manifest as hearing loss, is a potential side effect of vancomycin. Therefore, it’s important to monitor the client’s hearing during treatment.
C. Obtain an arterial blood gas (ABG)
Obtain an arterial blood gas (ABG). This is not typically required when administering vancomycin. ABGs are usually drawn to assess a patient’s acid-base balance and oxygenation status, not as a routine part of vancomycin administration.
D. Infuse the drug over 1-2 hours
Infuse the drug over 1-2 hours. Vancomycin should be administered over at least 60 minutes to avoid skin irritation. Infusing the drug too quickly can also increase the risk of Red Man Syndrome.
E. Obtain an ordered trough level prior to next scheduled dose
Obtain an ordered trough level prior to next scheduled dose. Monitoring vancomycin trough levels is important to ensure therapeutic efficacy and to avoid toxicity. Trough levels are typically drawn just before the next dose is due.
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Full Explanation
Choice A rationale
Assess for Red Man Syndrome. Vancomycin can cause a reaction known as Red Man Syndrome, which is characterized by flushing and/or an erythematous rash that affects the face, neck, and upper torso. This is not an allergic reaction, but rather a direct histamine-release effect of the drug.
Choice B rationale
Assess the client’s hearing. Ototoxicity, which can manifest as hearing loss, is a potential side effect of vancomycin. Therefore, it’s important to monitor the client’s hearing during treatment.
Choice C rationale
Obtain an arterial blood gas (ABG). This is not typically required when administering vancomycin. ABGs are usually drawn to assess a patient’s acid-base balance and oxygenation status, not as a routine part of vancomycin administration.
Choice D rationale
Infuse the drug over 1-2 hours. Vancomycin should be administered over at least 60 minutes to avoid skin irritation. Infusing the drug too quickly can also increase the risk of Red Man Syndrome.
Choice E rationale
Obtain an ordered trough level prior to next scheduled dose. Monitoring vancomycin trough levels is important to ensure therapeutic efficacy and to avoid toxicity. Trough levels are typically drawn just before the next dose is due.
Similar Questions
The client’s chart indicates the diagnosis of stage III peripheral arterial disease. Which nursing assessment finding correlates with this diagnosis?
A. Complaints of muscle cramps with exercise
Complaints of muscle cramps with exercise. While muscle cramps with exercise can be a symptom of peripheral arterial disease (PAD), they are more commonly associated with the earlier stages of the disease, known as intermittent claudication.
B. Pedal pulses are +1 bilaterally
Pedal pulses are +1 bilaterally. Reduced or absent pedal pulses can be a sign of PAD, but a finding of +1 pedal pulses does not necessarily correlate with stage III of the disease.
C. Complaints of burning pain during the night
Complaints of burning pain during the night. Stage III PAD, also known as critical limb ischemia, is characterized by more severe symptoms, including discomfort or pain in the feet or toes, even while at rest. Symptoms tend to worsen at night.
D. Tissue that is blackened on the great toe
Tissue that is blackened on the great toe. This is a sign of gangrene, which is a severe and potentially life-threatening complication of PAD2. However, it is not a typical finding in stage III PAD, and would more likely be seen in the most advanced stage of the disease.
Full Explanation
Choice A rationale
Complaints of muscle cramps with exercise. While muscle cramps with exercise can be a symptom of peripheral arterial disease (PAD), they are more commonly associated with the earlier stages of the disease, known as intermittent claudication.
Choice B rationale
Pedal pulses are +1 bilaterally. Reduced or absent pedal pulses can be a sign of PAD, but a finding of +1 pedal pulses does not necessarily correlate with stage III of the disease.
Choice C rationale
Complaints of burning pain during the night. Stage III PAD, also known as critical limb ischemia, is characterized by more severe symptoms, including discomfort or pain in the feet or toes, even while at rest. Symptoms tend to worsen at night.
Choice D rationale
Tissue that is blackened on the great toe. This is a sign of gangrene, which is a severe and potentially life-threatening complication of PAD2. However, it is not a typical finding in stage III PAD, and would more likely be seen in the most advanced stage of the disease.
Which client does the nurse recognize to have the greatest risk of an adverse reaction if prescribed potassium Penicillin G?
A. 55-year-old woman with coronary artery disease
55-year-old woman with coronary artery disease. While patients with coronary artery disease often have multiple comorbidities and may be on medications that could interact with Penicillin G, there is no specific increased risk of adverse reactions to Penicillin G in this population.
B. 21-year-old college senior who is being treated for Streptococcus
21-year-old college senior who is being treated for Streptococcus. Penicillin G is often used to treat Streptococcus infections. There is no specific increased risk of adverse reactions in this population unless the patient has a known allergy to penicillins.
C. 23-year-old woman who recently delivered and has mastitis
23-year-old woman who recently delivered and has mastitis. Penicillin G can be used to treat mastitis, an infection of the breast tissue that results in breast pain, swelling, warmth, and redness. There is no specific increased risk of adverse reactions in this population unless the patient has a known allergy to penicillins.
D. 65-year-old man with dehydration .
65-year-old man with dehydration. Dehydration can affect kidney function, and Penicillin G is excreted by the kidneys. Therefore, patients with dehydration or any other condition that reduces kidney function are at a higher risk of adverse reactions to Penicillin G3.
Full Explanation
Choice A rationale
55-year-old woman with coronary artery disease. While patients with coronary artery disease often have multiple comorbidities and may be on medications that could interact with Penicillin G, there is no specific increased risk of adverse reactions to Penicillin G in this population.
Choice B rationale
21-year-old college senior who is being treated for Streptococcus. Penicillin G is often used to treat Streptococcus infections. There is no specific increased risk of adverse reactions in this population unless the patient has a known allergy to penicillins.
Choice C rationale
23-year-old woman who recently delivered and has mastitis. Penicillin G can be used to treat mastitis, an infection of the breast tissue that results in breast pain, swelling, warmth, and redness. There is no specific increased risk of adverse reactions in this population unless the patient has a known allergy to penicillins.
Choice D rationale
65-year-old man with dehydration. Dehydration can affect kidney function, and Penicillin G is excreted by the kidneys. Therefore, patients with dehydration or any other condition that reduces kidney function are at a higher risk of adverse reactions to Penicillin G3.
A nurse gives a client 10 units of insulin lispro at 0630. When should the client have breakfast?
A. 0640
The correct answer is Choice A. Insulin lispro is a fast-acting insulin that starts to work about 15 minutes after injection. Therefore, the client should eat within 15 minutes of taking the insulin to prevent hypoglycemia. So, if the client takes the insulin at 0630, they should start eating at 06404
B. 0650
C. 0700
D. 0710
Full Explanation
The correct answer is Choice A. Insulin lispro is a fast-acting insulin that starts to work about 15 minutes after injection. Therefore, the client should eat within 15 minutes of taking the insulin to prevent hypoglycemia. So, if the client takes the insulin at 0630, they should start eating at 06404