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 C
Explanation
Rationale:
A. Monitoring alanine aminotransferase is important for liver function, but it is not the priority for a client on captopril.
B. Thyroid-stimulating hormone is not directly impacted by captopril and is not the priority lab value to monitor in this context.
C. Potassium is the priority laboratory value to monitor because captopril, an ACE inhibitor, can lead to hyperkalemia (elevated potassium levels), which can cause serious cardiac complications.
D. While magnesium levels are important to monitor, they are not specifically related to captopril therapy as potassium levels are.
Correct Answer is A
Explanation
Rationale:
A. Nitrofurantoin can cause brown-colored urine due to its pigment, and clients should be informed to report this as a common side effect and not a cause for alarm.
B. Nitrofurantoin is an antibiotic used to treat urinary tract infections and does not provide relief for peripheral nerve pain.
C. Nitrofurantoin should not be crushed, as it can affect the medication's absorption and effectiveness.
D. A cough is not a typical side effect of nitrofurantoin; however, if the client develops a cough, it could be a sign of a serious side effect, and they should notify the provider.