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kadejuah kadejuah
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6 years ago
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.
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Replies
wrote...
6 years ago
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.
kadejuah Author
wrote...
6 years ago
Much better than Coursehero
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