*NURSING > A-Level Question Paper > ATI General Nursing Questions and Answers (3).pdf (All)

ATI General Nursing Questions and Answers (3).pdf

Document Content and Description Below

1-The nurse administers IV vancomycin to a client with a methicillin-resistant Staphylococcus aureus infection. Which nursing actions are most appropriate? Select all that apply. 1. Assess client ... for lethargy and decreased deep tendon reflexes 2. Assess skin for flushing and red rash on face and torso 3. Infuse medication over at least 60 minutes 4. Monitor blood pressure during infusion 5. Observe IV site every 30 minutes for pain, redness, and swelling Explanation: When administering IV vancomycin, the nurse should assess for and work to prevent possible complications by performing the following:  Draw the prescribed trough level prior to administration. Therapeutic vancomycin levels range from 10-20 mg/L (6.9-13.8 μmol/L) for hemodynamically stable clients. Adverse effects of vancomycin toxicity include nephrotoxicity (eg, elevated creatinine levels) and ototoxicity (eg, hearing loss, vertigo, tinnitus).  Infuse medication over at least 60 minutes (≤10 mg/min). Faster rates increase the likelihood of complications (Option 3).  Monitor blood pressure during the infusion. Hypotension is a possible adverse effect (Option 4)  Assess for hypersensitivity. Red man syndrome is a nonallergic histamine reaction characterized by sudden onset of severe hypotension, flushing, and/or maculopapular rash of the face, neck, chest, and upper extremities (Option 2).  Monitor for anaphylaxis (eg, rash, pruritus, laryngeal edema, wheezing).  Observe IV site every 30 minutes for pain, redness, or swelling. Vancomycin is a vesicant and may cause thrombophlebitis or, if extravasation occurs, tissue necrosis. Administration using a central venous catheter is preferred; however, a peripheral IV may be used for short-term therapy (Option 5). (Option 1) Assessment of deep tendon reflexes is appropriate with magnesium sulfate administration. Manifestations of hypermagnesemia include lethargy, nausea, vomiting, and decreased deep tendon reflexes. Educational objective: Nursing care of clients receiving IV vancomycin includes drawing prescribed trough levels before drug administration, infusing the drug over at least 60 minutes, monitoring the client during administration (eg, blood pressure, respiratory status, signs of hypersensitivity/anaphylaxis), and assessing the IV site during and after administration. [Show More]

Last updated: 1 year ago

Preview 1 out of 58 pages

Buy Now

Instant download

We Accept: