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 being taught about the use of enoxaparin (Lovenox) for the prevention of deep vein thrombosis. Which instruction should the nurse include in the teaching plan?

Correct answer: C

Rationale: Enoxaparin (Lovenox) is administered subcutaneously at the same time each day to maintain consistent blood levels. Injecting the medication into the muscle is incorrect, as it should be given subcutaneously. Massaging the injection site should be avoided to prevent bruising. The air bubble in the prefilled syringe should not be expelled, as it ensures the full dose is administered.

3. Which laboratory test should the nurse monitor to determine the effectiveness of heparin therapy for a client with deep vein thrombosis?

Correct answer: C

Rationale: The activated partial thromboplastin time (aPTT) is the specific laboratory test used to monitor the effectiveness of heparin therapy in patients with deep vein thrombosis. It measures the time it takes for blood to clot and is crucial in assessing the therapeutic range of heparin. Platelet count, prothrombin time (PT), and hemoglobin and hematocrit levels are important parameters in assessing coagulation and blood status but do not directly indicate the effectiveness of heparin therapy.

4. Mafenide acetate (Sulfamylon) is prescribed for a client with a burn injury. When applying the medication, the client complains of local discomfort and burning. Which of the following is the most appropriate nursing action?

Correct answer: C

Rationale: The correct action is to inform the client that local discomfort and burning are normal reactions to Mafenide acetate. This medication is used to treat burns by reducing bacteria in avascular tissues. Discontinuing the medication or applying a thinner film than prescribed is not necessary or recommended in this situation.

5. A healthcare professional prepares to administer sodium polystyrene sulfonate (Kayexalate) to a client. Before administering the medication, the professional reviews the action of the medication and understands that it:

Correct answer: B

Rationale: Sodium polystyrene sulfonate, such as Kayexalate, is a cation exchange resin that functions by releasing sodium ions in exchange for primarily potassium ions. This medication is commonly used to treat hyperkalemia, a condition characterized by elevated levels of potassium in the blood.

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