A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take?
a. Administer it over 30 minutes using an IV pump.
b. Give the client diphenhydramine (Benadryl) before the drug.
c. Assess the IV site at least every 2 hours for thrombophlebitis.
d. Ensure that the client has increased oral intake during therapy.
ANS: C
Vancomycin is very irritating to the veins and can easily cause thrombophlebitis. This drug is given over at least 60 minutes; although it can cause histamine release (leading to "red man syndrome"), it is not customary to administer diphenhydramine before starting the infusion. Increasing oral intake is not specific to vancomycin therapy.
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The nurse is palpating the uterus of a woman who is 8 weeks' pregnant. Which finding would be considered to be most consistent with this stage of pregnancy?
a. The uterus seems slightly enlarged and softened. b. It reaches the pelvic brim and is approximately the size of a grapefruit. c. The uterus rises above the pelvic brim and is approximately the size of a cantaloupe. d. It is about the size of an avocado, approximately 8 cm across the fundus.
Which statement made by a client with a spinal cord injury, who is now living at home, indicates correct understanding of preventive strategies for respiratory problems?
A. "I use an incentive spirometer every 8 hours." B. "I take two aspirins right away if I have a fever." C. "I take a cough medicine to prevent excessive coughing." D. "I spend most of my time on my right side so I don't aspirate."
Signs and symptoms of meningitis include
A) diarrhea. B) stiff neck. C) palpitations. D) abdominal pain.
A nurse is discussing adenosine with a nursing student. Which statement by the student indicates a need for further teaching?
a. "Adenosine acts by suppressing action potentials in the SA and AV nodes."
b. "Adenosine can be used to prevent parox-ysmal supraventricular tachycardia and Wolff-Parkinson-White syndrome."
c. "Adenosine has a half-life that lasts only a few seconds and must be given intrave-nously."
d. "Adenosine is not effective for treating atrial fibrillation, atrial flutter, or ventri-cular dysrhythmias."