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 diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which action is a priority nursing intervention?

Correct answer: C

Rationale: The priority nursing intervention for a client receiving tissue plasminogen activator (alteplase) for an acute myocardial infarction is to monitor for signs of bleeding. Alteplase is a thrombolytic medication that can lead to hemorrhage as a complication. Therefore, closely monitoring the client for any signs of bleeding is essential to promptly address and manage this potential adverse effect.

3. The client has a PRN prescription for loperamide hydrochloride (Imodium). The nurse understands that this medication is used for which condition?

Correct answer: C

Rationale: Loperamide hydrochloride (Imodium) is an antidiarrheal medication commonly used to manage episodes of diarrhea. It works by slowing down gut movement and reducing the frequency of bowel movements. Loperamide is not indicated for constipation, abdominal pain, or hematest-positive nasogastric tube drainage. It is specifically useful in acute and chronic diarrhea, such as in cases of inflammatory bowel disease, to help control symptoms and decrease fluid loss.

4. A client with a history of chronic heart failure is prescribed spironolactone (Aldactone). Which of the following statements indicates that the client understands the medication teaching?

Correct answer: A

Rationale: The correct statement is 'I will avoid potassium-rich foods.' Spironolactone (Aldactone) is a potassium-sparing diuretic, which can lead to hyperkalemia if potassium intake is not regulated. Therefore, avoiding potassium-rich foods is crucial to prevent this complication. Using a salt substitute can also increase potassium levels. Monitoring weight daily is essential in heart failure management, but it is not specific to spironolactone. Increasing fluid intake as prescribed is generally recommended for heart failure management but is not directly related to spironolactone use.

5. The nurse provides medication instructions to an older hypertensive client who is taking 20 mg of lisinopril (Prinivil, Zestril) orally daily. The nurse evaluates the need for further teaching when the client states which of the following?

Correct answer: A

Rationale: Lisinopril should be taken daily as prescribed and not skipped. Skipping doses can lead to ineffective treatment.

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After the initial dose, which of the following is the priority assessment for a client being treated for acute congestive heart failure with intravenously administered bumetanide?
A client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, a nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, 'My chest still hurts.' Select the appropriate actions that the nurse should take.

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