Abrams' Clinical Drug Therapy
Rationales for Nursing Practice
13th Edition
• Author(s)Geralyn Frandsen;
Sandra Pennington
TEST BANK
,Question 1
The nurse is preparing to administer an initial dose of
intravenous vancomycin to a client with a severe methicillin-
resistant Staphylococcus aureus (MRSA) infection. Which action
should the nurse take first to ensure patient safety?
A. Verify that a baseline serum creatinine level has been
obtained. B. Infuse the medication over a minimum of 30
minutes. C. Assess the client for a sudden onset of severe
maculopapular rash. D. Check the client's blood pressure
immediately before the infusion.
Correct Answer: A
Rationale: Vancomycin is highly nephrotoxic. The nurse must
verify baseline renal function (serum creatinine and blood urea
nitrogen) before administering the initial dose to establish a
baseline for monitoring potential toxicity. Vancomycin must be
infused slowly over at least 60 minutes, not 30 minutes, to
prevent vancomycin flushing syndrome (formerly known as "red
man syndrome"). While assessing for a rash and monitoring
blood pressure are important during therapy, checking baseline
renal function is the priority safety action before the first dose
is hung.
Question 2
,A client who has been taking phenelzine, a monoamine oxidase
inhibitor (MAOI), for severe depression arrives at the
emergency department reporting a sudden, throbbing
headache, neck stiffness, and nausea. The client's blood
pressure is 210/120 mmHg. Which question by the nurse is
most appropriate to help determine the cause of this
condition?
A. "Have you taken an extra dose of your antidepressant in the
last 24 hours?" B. "Did you consume any aged cheeses, cured
meats, or red wine recently?" C. "Have you been experiencing
any increased stress or anxiety at home?" D. "When was the
last time you had your potassium levels checked?"
Correct Answer: B
Rationale: Phenelzine is an MAOI. Consuming foods high in
tyramine—such as aged cheeses, cured meats, beer, and red
wine—while taking an MAOI can precipitate a hypertensive
crisis, which matches this client's presentation (severe
headache, extremely elevated blood pressure, neck stiffness).
This is an adverse drug-food interaction rather than a simple
drug overdose. Stress and potassium levels do not acutely cause
a hypertensive crisis of this magnitude in relation to MAOI
therapy.
Question 3
, The nurse is reviewing the laboratory results for a client
receiving a continuous intravenous heparin infusion for a deep
vein thrombosis. The client's activated partial thromboplastin
time (aPTT) is 110 seconds. The control value is 30 seconds.
Which action should the nurse take first?
A. Maintain the current infusion rate and recheck the aPTT in 4
hours. B. Stop the heparin infusion immediately and notify the
healthcare provider. C. Prepare to administer vitamin K
intramuscularly. D. Increase the infusion rate slightly to reach
the upper therapeutic limit.
Correct Answer: B
Rationale: The therapeutic range for aPTT during heparin
therapy is typically 1.5 to 2.5 times the control value. With a
control value of 30 seconds, the therapeutic range is 45 to 75
seconds. An aPTT of 110 seconds indicates significant over-
anticoagulation and a high risk for spontaneous bleeding. The
nurse must stop the infusion immediately to prevent
hemorrhage and notify the provider. Vitamin K is the antidote
for warfarin, not heparin; protamine sulfate is the antidote for
heparin if active bleeding occurs.
Question 4
A client diagnosed with open-angle glaucoma is prescribed
timolol ophthalmic drops. The nurse is providing education to
the client regarding proper administration techniques. Which
Rationales for Nursing Practice
13th Edition
• Author(s)Geralyn Frandsen;
Sandra Pennington
TEST BANK
,Question 1
The nurse is preparing to administer an initial dose of
intravenous vancomycin to a client with a severe methicillin-
resistant Staphylococcus aureus (MRSA) infection. Which action
should the nurse take first to ensure patient safety?
A. Verify that a baseline serum creatinine level has been
obtained. B. Infuse the medication over a minimum of 30
minutes. C. Assess the client for a sudden onset of severe
maculopapular rash. D. Check the client's blood pressure
immediately before the infusion.
Correct Answer: A
Rationale: Vancomycin is highly nephrotoxic. The nurse must
verify baseline renal function (serum creatinine and blood urea
nitrogen) before administering the initial dose to establish a
baseline for monitoring potential toxicity. Vancomycin must be
infused slowly over at least 60 minutes, not 30 minutes, to
prevent vancomycin flushing syndrome (formerly known as "red
man syndrome"). While assessing for a rash and monitoring
blood pressure are important during therapy, checking baseline
renal function is the priority safety action before the first dose
is hung.
Question 2
,A client who has been taking phenelzine, a monoamine oxidase
inhibitor (MAOI), for severe depression arrives at the
emergency department reporting a sudden, throbbing
headache, neck stiffness, and nausea. The client's blood
pressure is 210/120 mmHg. Which question by the nurse is
most appropriate to help determine the cause of this
condition?
A. "Have you taken an extra dose of your antidepressant in the
last 24 hours?" B. "Did you consume any aged cheeses, cured
meats, or red wine recently?" C. "Have you been experiencing
any increased stress or anxiety at home?" D. "When was the
last time you had your potassium levels checked?"
Correct Answer: B
Rationale: Phenelzine is an MAOI. Consuming foods high in
tyramine—such as aged cheeses, cured meats, beer, and red
wine—while taking an MAOI can precipitate a hypertensive
crisis, which matches this client's presentation (severe
headache, extremely elevated blood pressure, neck stiffness).
This is an adverse drug-food interaction rather than a simple
drug overdose. Stress and potassium levels do not acutely cause
a hypertensive crisis of this magnitude in relation to MAOI
therapy.
Question 3
, The nurse is reviewing the laboratory results for a client
receiving a continuous intravenous heparin infusion for a deep
vein thrombosis. The client's activated partial thromboplastin
time (aPTT) is 110 seconds. The control value is 30 seconds.
Which action should the nurse take first?
A. Maintain the current infusion rate and recheck the aPTT in 4
hours. B. Stop the heparin infusion immediately and notify the
healthcare provider. C. Prepare to administer vitamin K
intramuscularly. D. Increase the infusion rate slightly to reach
the upper therapeutic limit.
Correct Answer: B
Rationale: The therapeutic range for aPTT during heparin
therapy is typically 1.5 to 2.5 times the control value. With a
control value of 30 seconds, the therapeutic range is 45 to 75
seconds. An aPTT of 110 seconds indicates significant over-
anticoagulation and a high risk for spontaneous bleeding. The
nurse must stop the infusion immediately to prevent
hemorrhage and notify the provider. Vitamin K is the antidote
for warfarin, not heparin; protamine sulfate is the antidote for
heparin if active bleeding occurs.
Question 4
A client diagnosed with open-angle glaucoma is prescribed
timolol ophthalmic drops. The nurse is providing education to
the client regarding proper administration techniques. Which
