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 ["A","D","E"]
Explanation
Rationale:
A. Blurred vision is a common side effect of anticholinergic medications due to their effect on the eye muscles and pupil dilation.
B. Polyuria is not typically associated with anticholinergic medications; these medications may actually lead to urinary retention.
C. A productive cough is not an expected adverse effect of anticholinergic medications; instead, they may cause dry mucous membranes and a dry cough.
D. Tachycardia can occur as anticholinergic medications block the effects of acetylcholine on the heart, leading to increased heart rate.
E. Constipation is a well-known side effect of anticholinergic medications because they reduce gastrointestinal motility.
Correct Answer is B
Explanation
Rationale:
A. A heart rate of 105/min is slightly elevated, but it does not require immediate intervention unless the client is symptomatic or has other concerning signs.
B. Infiltration of the peripheral IV requires immediate intervention, as it can lead to tissue damage and prevent the medication from being effectively delivered. The nurse should stop the infusion, assess the site, and take appropriate action.
C. Increased blood pressure is a common effect of dopamine administration and does not necessarily require urgent intervention unless it becomes critically high or is associated with other adverse symptoms.
D. Occasional PVCs can occur during dopamine infusion and can be monitored unless they become frequent or symptomatic; they typically do not require immediate intervention.