Unit 3: IV Therapy: Complex Therapies and Medications
When assessing a patient receiving morphine sulfate 2 mg every 10 minutes via PCA pump, the nurse should take action as soon as the patient's respiratory rate would drop down to or below which of the following parameters? -16 breaths/min -14 breaths/min -12 breaths/min -10 breaths/min
-12 Breaths/min
A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions is the priority for the nurse to take? -Provide antiemetic -Make the client NPO -Administer a stimulant laxative -Auscultate bowel sounds
-Auscultate bowel sounds (Opioids used in patient controlled analgesia cause adverse effects that include constipation, nausea and vomiting, urinary retention, and pruritus. Nausea and vomiting may occur initially as a side effect but often resolves within 24 to 48 hours of starting the opioid. It is important for the nurse to assess the actual cause of the nausea in order to treat it effectively, which requires an evaluation of the client's bowel sounds and bowel habits.)
A nurse is preparing to administer IV vancomycin to a client who has methicillin resistant staphylococcus aureus (MRSA). Which of the following actions should the nurse plan to take? -Change the IV site w/ each new dose. -Inform the client to expect urine to become pink in color. -Administer the medication with an NSAID to minimize infusion discomfort. -Infuse the medication over at least 60min.
-Infuse the medication over at least 60 min. (Rapid infusion of vancomycin can cause a phenomenon known as Red Man syndrome. The nurse can minimize the risk of this from occurring by slowly infusing the medication over a period of 60min or longer.) Incorrect: -Administer the medication with an NSAID to minimize infusion discomfort (Nephrotoxic medications, including NSAIDs, can increase the risk of kidney damage. The nurse should not give these medications concurrently.)
What are the manifestations of aminoglycoside toxicity?
-Ototoxicity (tinnitus; headache; hearing loss; nausea; dizziness; vertigo; unsteadiness) -Nephrotoxicity (proteinuria, casts in the urine, dilute urine, ↑BUN, ↑creatinine; AEB hematuria, cloudy urine) -Intense Neuromuscular Blockade (respiratory depression, muscle weakness, paralysis) -Hypersensitivity (Rash, pruritus, paresthesia, urticaria)
A nurse is reviewing a client's peak and trough levels of gentamicin. The peak should be 6-8 mcg/mL and the trough should be 0.5-1 mcg/mL. The client's peak is 10 mcg/mL and his trough is 2.3 mcg/mL. Which of the following clinical manifestations should the nurse expect with these findings? (SAP) -Insomnia -Tinnitus -Persistent headache -Constipation -Xerostomia
-Tinnitus -Persistent headache (Both signs of ototoxicity)