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 clinic nurse prepares to administer an MMR (measles, mumps, rubella) vaccine to a child. How is this vaccine best administered?

Correct answer: C

Rationale: The MMR vaccine is best administered subcutaneously in the outer aspect of the upper arm. This route allows for proper absorption and efficacy of the vaccine while minimizing the risk of injury or discomfort to the child.

3. The client has a new prescription for metoclopramide (Reglan). On review of the chart, the nurse identifies that this medication can be safely administered with which condition?

Correct answer: D

Rationale: Metoclopramide, also known as Reglan, is commonly used to manage vomiting following cancer chemotherapy. It acts as a gastrointestinal stimulant and antiemetic, aiding in relieving nausea and vomiting associated with chemotherapy. Metoclopramide should be avoided in conditions like intestinal obstruction, peptic ulcer with melena, and diverticulitis with perforation due to its prokinetic properties that can worsen these conditions. Therefore, the correct answer is D: Vomiting following cancer chemotherapy.

4. The healthcare provider is reviewing the history and physical examination of a client who will be receiving asparaginase (Elspar), an antineoplastic agent. The healthcare provider consults with the registered nurse regarding the administration of the medication if which of the following is documented in the client's history?

Correct answer: A

Rationale: Asparaginase is contraindicated in clients with a history of pancreatitis due to the risk of impairing pancreatic function and causing complications. Therefore, the healthcare provider should consult with the registered nurse to assess the client's history of pancreatitis before administering asparaginase.

5. A health care provider (HCP) writes a prescription for digoxin (Lanoxin), 0.25 mg daily. The nurse teaches the client about the medication and tells the client that it is important to:

Correct answer: D

Rationale: When taking digoxin, monitoring the pulse rate is essential due to its potential effects on heart rate. Digoxin can lead to bradycardia, where the pulse rate drops significantly. Withholding the medication and promptly contacting the healthcare provider if the pulse falls below 60 beats per minute is crucial to prevent severe complications and ensure appropriate management. Choices A, B, and C are incorrect because counting radial and carotid pulses, checking blood pressure, or stopping the medication based on a pulse rate higher than 100 beats per minute are not the primary monitoring parameters for a client taking digoxin.

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