A patient admitted with an infected below-the-knee amputation (BKA) and heart failure (HF) is taking vancomycin (Vancocin) and furosemide (Lasix). Which of the following is the most important instruction the nurse should provide?
a. Report any ringing in the ears or dizziness.
b. Report frequent nocturia.
c. Elevate the affected extremity.
d. Keep the head of the bed at 30 degrees.
ANS: A
Both vancomycin and furosemide are ototoxic; therefore the patient should be instructed to notify the nurse of any ringing in the ears (tinnitus) and/or dizziness.
Nocturia is expected with administration of furosemide, depending on the time of day the drug is administered.
Elevating the extremity is important, but it is not the most important issue in this case.
Elevating the head of the bed to 30 degrees may be good for a patient with HF, but it is not the most important issue in this case.
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