a nurse is caring for a client who is receiving vancomycin vancocin which of the following is the most important action for the nurse to take
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Nursing Elites

HESI RN

HESI Pharmacology Quizlet

1. A client is receiving vancomycin (Vancocin). Which of the following is the most important action for the nurse to take?

Correct answer: A

Rationale: The most important action for the nurse to take when a client is receiving vancomycin is to monitor for signs of nephrotoxicity. Vancomycin can cause kidney damage, so monitoring kidney function and signs of nephrotoxicity are crucial to prevent harm. While monitoring for ototoxicity and ensuring adequate hydration are important nursing actions, they are not as critical as preventing nephrotoxicity when administering vancomycin.

2. A client is receiving an intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. The nurse notes redness and swelling at the site, along with a slowed infusion rate. What is the appropriate action for the nurse to take?

Correct answer: A

Rationale: When a client complains of pain at the IV insertion site, and there are signs of extravasation such as redness and swelling, it is crucial to notify the healthcare provider immediately. Extravasation of antineoplastic medications can cause tissue damage, pain, and necrosis if they escape into surrounding tissues. Prompt action is necessary to prevent further complications and ensure appropriate management of the situation. Administering pain medication, applying ice, or elevating the extremity are not appropriate actions in cases of suspected extravasation. These actions do not address the underlying issue of potential tissue damage and necrosis that can occur due to the leakage of antineoplastic medication.

3. A client is receiving furosemide (Lasix) and is being discharged. What should the nurse include in the teaching plan?

Correct answer: C

Rationale: The correct answer is to instruct the client to change positions slowly to prevent dizziness. Furosemide (Lasix) is a diuretic that can lead to orthostatic hypotension, causing dizziness. Consuming potassium-rich foods is essential to prevent hypokalemia when taking furosemide. Taking the medication in the morning helps reduce the need for frequent urination at night. Encouraging the client to maintain an adequate fluid intake is crucial to prevent dehydration while on this medication.

4. When a client taking warfarin sodium (Coumadin) is prescribed ciprofloxacin (Cipro), the nurse should closely monitor the client for which potential effect of this drug interaction?

Correct answer: A

Rationale: When ciprofloxacin (Cipro) is given with warfarin sodium (Coumadin), it can potentiate the effects of warfarin, leading to an increased risk of bleeding. Therefore, the nurse should closely monitor the client's INR levels and watch for signs of bleeding such as bruising, petechiae, or black tarry stools.

5. A community health nurse visits a client at home. Prednisone 10 mg orally daily has been prescribed for the client. The nurse reinforces teaching for the client about the medication. Which statement, if made by the client, indicates that further teaching is necessary?

Correct answer: A

Rationale: Aspirin and other over-the-counter medications should not be taken without consulting the health care provider (HCP). The client needs to take the medication at the same time every day and avoid caffeine-containing foods and fluids to prevent steroid-ulcer development.

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