A patient is receiving vancomycin. Which physiological function is the priority for the nurse to assess?
Vision
Heart tones
Bowel sounds
Hearing
The Correct Answer is D
A. Vision is not commonly affected by vancomycin, so it is not a priority to assess.
B. Heart tones are not directly impacted by vancomycin and do not require immediate monitoring unless there are specific cardiovascular concerns.
C. Bowel sounds are not directly influenced by vancomycin and do not need to be prioritized in this case.
D. Vancomycin is known to be ototoxic, especially in high doses or with prolonged use, so monitoring for signs of hearing loss or tinnitus is essential to prevent potential irreversible damage.
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Correct Answer is D
Explanation
A. A 3-mL syringe is not appropriate for administering U-500 insulin, as the concentration may not allow for accurate dosing at such a small volume.
B. A U-100 syringe is designed for U-100 insulin and would not provide accurate measurement for U-500 insulin.
C. A needleless syringe may be useful in certain contexts, but it does not specifically provide the necessary precision for insulin dosage.
D. A tuberculin syringe is suitable for administering small doses (like 0.3 mL) and provides more accurate measurement for high-concentration insulin such as U-500.
Correct Answer is C
Explanation
A. Discontinuing pain medication may not be appropriate, as it can lead to inadequate pain management for the patient. Pain management is crucial for terminally ill patients.
B. While abdominal massage may help relieve mild constipation, it is not a reliable primary intervention for more severe constipation caused by medication.
C. Laxatives are commonly prescribed for constipation related to pain medication and are an effective method to promote bowel movements, making this the best choice.
D. Administering enemas twice daily can be excessive and may cause discomfort or lead to dependency, making this option less favorable than using laxatives.