A nurse is caring for a client who has a prescription for vancomycin 1 g IV intermittent infusion over 30 min every 12 hr. Which of the following actions should the nurse take?
Request a serum trough level blood draw for 60 min after completion of infusion.
Change the infusion site after each dose administration.
Contact the provider for prescription clarification.
Request a serum peak level to be drawn 30 min prior to infusion.
The Correct Answer is A
Rationale:
A. Requesting a serum trough level blood draw for 60 minutes after the completion of the infusion is appropriate for monitoring the therapeutic levels of vancomycin and ensuring it is within the desired range to prevent toxicity.
B. Changing the infusion site after each dose administration is not necessary unless there is an issue such as infiltration or phlebitis; typically, the site can be used for multiple doses if it remains patent and functional.
C. Contacting the provider for prescription clarification is not needed unless there are specific concerns about the medication or the administration protocol; in this case, the order is clear and standard.
D. Requesting a serum peak level to be drawn 30 minutes prior to infusion is incorrect, as the peak level should be drawn 30 minutes after the completion of the infusion, not before the next dose.
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Correct Answer is B
Explanation
Rationale:
A. Dyspepsia: While dyspepsia can be uncomfortable, it is not a critical finding that requires immediate reporting to the provider. It may be a common side effect of statins but typically does not warrant urgent intervention.
B. Elevated creatine kinase: An elevated creatine kinase level can indicate muscle damage, which is a serious side effect associated with rosuvastatin and other statins. This finding requires immediate reporting to prevent complications such as rhabdomyolysis.
C. Headache: A headache may occur with many medications and does not usually require immediate reporting unless it is severe or persistent.
D. Mostly cloudy: This option does not pertain to any specific clinical finding or symptom and is therefore not relevant to the question.
E. Decreased HDL cholesterol: While low HDL cholesterol can be a concern, it is not as urgent as elevated creatine kinase levels and typically does not require immediate action.
Correct Answer is D
Explanation
Rationale:
A. Acetylcysteine is not indicated for gastrointestinal bleeding; other treatments are used for that condition.
B. Acute bronchospasm is treated with bronchodilators rather than acetylcysteine.
C. Morphine toxicity requires other interventions, such as opioid antagonists (e.g., naloxone), and acetylcysteine is not effective in this case.
D. Acetylcysteine is specifically indicated for acetaminophen toxicity as it acts as an antidote, replenishing glutathione stores and preventing liver damage from toxic metabolites.