The client has MRSA and receives vancomycin (Vancocin) intravenously (IV). The nurse assesses an upper body rash and decreased urine output. What is the nurse's priority action?
1. Hold the next dose of vancomycin (Vancocin), and notify the physician.
2. Obtain a stat X-ray, and notify the physician.
3. Administer an antihistamine, and notify the physician.
4. Obtain a sterile urine specimen, and notify the physician.
Correct Answer: 1
Rationale 1: Upper body rash and decreased urine output are most likely symptoms of vancomycin (Vancocin) toxicity, so the medication should be held and the physician notified.
Rationale 2: There is no reason to obtain a chest x-ray.
Rationale 3: The nurse should collaborate with the physician regarding medications for treatment of this situation.
Rationale 4: The client's symptoms are most likely not due to a urinary tract infection, so a sterile urine specimen is not indicated.
You might also like to view...
A perinatal nurse is assessing a woman who is approximately 10 weeks pregnant. The woman smells like cigarette smoke. What actions by the nurse are best? (Select all that apply.)
A. Advise her to stop smoking now so that the baby can be of normal weight. B. Ask the woman if either she or her partner smokes. C. Determine how many cigarettes she smokes a day. D. Describe the behavior problems her child may develop. E. Explain that nicotine deprives the fetus of oxygen.
To perform a deep tendon reflex measurement, you should:
a. briskly tap the tendon with the rubber end of the hammer. b. place the hammer firmly on the tendon for 3 to 5 seconds. c. tap the silver end of the hammer on the tendon. d. use the needle implement to determine sensory perception.
When planning a family session for a client with bulimia nervosa, the nurse should consider which of the following regarding family dynamics?
A) Family members may be over-involved with the client. B) Families of clients with bulimia nervosa become enmeshed. C) Family members of individuals with bulimia nervosa tend to bond together. D) Family members tend to isolate from one another.
When the nurse is working with a child who has a low platelet count, the nurse will teach the family and the child to avoid which of the following?
a. engaging in contact sports or any activity that has a risk of physical injury b. taking daily vitamins with mineral supplements or zinc supplements c. herbal teas of any type d. leaving the house for any reason