Difficulty: Medium Average Score: 72% Simulated

Passage / Scenario

History and Physical
The client is a 75-year-old female admitted to the preoperative area to prepare for pacemaker insertion. The client reports she is having this done because her heart rate has been staying very low, she is always tired, and she has passed out once from a low heart rate. The client has a history of worsening symptomatic bradycardia and a history of atrial fibrillation controlled by medication. She has been off anticoagulants for 4 days to prepare for the procedure.
NursesÔÇÖ Notes
0700:
Laboratory specimens have been drawn and completed during a preadmission visit. After changing clothes and settling into bed, the client was placed on continuous monitoring. Admission process completed.
0800:
Peripheral IV (PIV) started in the right antecubital with a 20-gauge catheter. IV fluids of 0.9% sodium chloride started at 50 mL/hr. Cardiac surgeon in to see the client and answer questions about the procedure.
0830:
Client reports no known allergies. Vancomycin 1 gram in 250 mL 0.9% sodium chloride started at 125 mL/hr as endocarditis prophylaxis.
Laboratory Results
Laboratory Test Result Reference Range
White blood cells (WBC) 6,500/mm┬│ (6.5 x 10Ôü╣/L) 5,000 to 10,000/mm┬│
Red blood cells (RBC) 3.78 x 10┬╣┬▓/L 4.2 to 5.4 x 10┬╣┬▓/L
Hemoglobin (Hgb) 11.2 g/dL (6.95 mmol/L) 12 to 16 g/dL (7.4 to 9.9 mmol/L)

Flow Sheet
0700
Vital Signs
ÔÇó Temperature: 97.6┬░F (36.4┬░C) orally
ÔÇó Heart rate: 44 beats/minute
ÔÇó Respiratory rate: 18 breaths/minute
ÔÇó Blood pressure: 136/80 mm Hg

The nurse is preparing the clientÔÇÖs plan of care. Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

The nurse is preparing the clientÔÇÖs plan of care. Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

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