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.
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.
Global Rationale: 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. There is no reason to obtain a chest x-ray. The nurse should collaborate with the physician regarding medications for treatment of this situation.
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 triage nurse in the emergency department is assessing a 78-year-old man. It is determined that the patient is experiencing severe digoxin toxicity. What drug will the nurse administer immediately?
A) Inamrinone (Inocor) B) Digoxin immune Fab (Digibind) C) Verapamil hydrochloride (Calan) D) Quinidine sulfate
The nurse is caring for a client in the immediate postoperative period (PACU). Which intervention would the nurse implement to reduce the risk of thrombophlebitis?
1. Leg exercises 2. Cough every 2 hours 3. Ambulate every 2 hours 4. Oxygen by mask
J.R. is a 28-year-old man who was doing home repairs. He fell from the top of a 6-foot stepladder, striking
his head on a large rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. the neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room. What steps will you take to assess J.R.?
When caring for a patient with osteoporosis, which of the following is the most important action to take to minimize progression of the disease?
a. Take a calcium supplement twice a day. b. Start a weight-bearing exercise program. c. Avoid strenuous activity that puts stress on the bones. d. Schedule regular healthcare checkups.