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Vancomycin (glycopeptide antibiotic) NCLEX questions

Terms in this set (186)

A nurse observes a red streak and palpates the vein as hard and cordlike at the intravenous (IV) site of a patient receiving cefepime [Maxipime]. Which assessment should the nurse make about the IV site?

a. An allergic reaction has developed to the drug solution.
b. The drug has infiltrated the extravascular tissues.
c. Phlebitis of the vein used for the antibiotic has developed.
d. Local infection from bacterial contamination has occurred.
Answer: C
IV cephalosporins may cause thrombophlebitis. To minimize this, the injection site should be rotated and a dilute solution should be administered slowly. An allergic response would be shown as itching, redness, and swelling. Infiltration would show as a pale, cool, and puffy IV site. Infection would show as pus, tenderness, and redness.
A patient develops flushing, rash, and pruritus during an IV infusion of vancomycin [Vancocin]. Which action should a nurse take?

a. Reduce the infusion rate.
b. Administer diphenhydramine [Benadryl].
c. Change the IV tubing.
d. Check the patency of the IV.
Answer: A
When vancomycin is infused too rapidly, histamine release may cause the patient to develop hypotension accompanied by flushing and warmth of the neck and face; this phenomenon is called red man syndrome. Diphenhydramine is not necessary if the infusion is administered slowly over at least 60 minutes. Changing the IV tubing would not help the symptoms. The patency of the IV needs to be checked before the administration is started.
A patient who is receiving vancomycin [Vancocin] IV for a methicillin-resistant Staphylococcus aureus (MRSA) infection asks a nurse, "Why can't I take this medicine in a pill?" Which response should the nurse make?

a. "The prescription could be changed, because vancomycin comes in two forms."
b. "You're allergic to penicillin, and this is the only way this medication can be given."
c. "It will cause too much loss of appetite and nausea if given in the oral form."
d. "It is more effective by IV, because the pill form will stay in the digestive tract."
Answer: D
Because of its chemical size and weight, vancomycin is absorbed poorly in the gastrointestinal (GI) tract and is given parenterally for most infections. It is used for serious infections caused by organisms such as MRSA and in patients with susceptible organisms allergic to penicillins. Oral administration is used only for infections of the intestine. It is not associated with loss of appetite or nausea.
A patient who is receiving ceftriaxone has all of these medications ordered. The nurse monitors the patient for an adverse effect related to an interaction with which medication?

a. Regular insulin
b. Ampicillin [Polycillin]
c. Naproxen [Naprosyn]
d. Bisacodyl [Dulcolax]
Answer: C

Three cephalosporins—cefmetazole [Zefazone], cefoperazone [Cefobid], and cefotetan [Cefotan]—cause bleeding tendencies. Caution should be used during concurrent use of anticoagulants and other nonsteroidal medications. Regular insulin, ampicillin, and bisacodyl are unrelated to adverse effects with cefotetan.
A patient is receiving vancomycin [Vancocin]. The nurse identifies what as the most common toxic effect of vancomycin therapy?

a. Ototoxicity
b. Hepatotoxicity
c. Renal toxicity
d. Cardiac toxicity
Answer: C
The most common toxic effect of vancomycin [Vancocin] therapy is renal toxicity. Although ototoxicity may occur, it is rare. The liver and heart are not affected when vancomycin is used.
Before administering a cephalosporin to a patient, it is most important for the nurse to assess the patient for an allergy history to what?

a. Soy products
b. Peanuts
c. Penicillins
d. Opioids
Answer: C
The cephalosporins are beta-lactam antibiotics similar in structure and actions to the penicillins. They are contraindicated in patients with a history of severe allergic reactions to penicillins. The use of soy products, peanuts, and opioids is unrelated to cephalosporins.
Which statements about vancomycin [Vancocin] does the nurse identify as true? (Select all that apply.)

a. Vancomycin is the most widely used antibiotic in U.S. hospitals.
b. Vancomycin is effective in the treatment of Clostridium difficile infection.
c. Vancomycin is effective in the treatment of MRSA infections.
d. Patients who are allergic to penicillin are also allergic to vancomycin.
e. The major toxicity of vancomycin therapy is liver failure.
Answers: a,b,c
Patients who are allergic to penicillin are able to take vancomycin. The major toxicity of vancomycin therapy is kidney failure. The other three statements are true.
Which instructions will the nurse include when teaching a patient about cephalosporin therapy? (Select all that apply.)

a. "Notify your healthcare provider if you develop diarrhea."
b. "Take aspirin if you develop a headache."
c. "Notify your healthcare provider if you develop a rash."
d. "Cephalosporins may not be taken with food."
e. "Do not take cephalosporins if you have lactose intolerance."
Answers: A, C
Cephalosporins may enhance bleeding tendencies, so drugs such as aspirin that may promote bleeding should be avoided. Cephalosporins may be taken with food, and they are safe to take if a patient has lactose intolerance. Severe diarrhea should be reported, because it may indicate the development of C. difficile infection. Any indication of an allergic reaction, including a rash, should be reported to the healthcare provider.
Thirty minutes after receiving an intramuscular (IM) injection of penicillin G [Pfizerpen], a patient reports itching and redness at the injection site. Which action should the nurse take first?

a. Elevate the lower legs.
b. Place an ice pack on the site.
c. Make sure the patient stays calm.
d. Administer subcutaneous epinephrine.
Answer: d
Itching and redness at the IM injection site indicate an allergy to penicillin. The primary treatment is epinephrine (subcutaneous, IM, or IV) plus respiratory support. Elevation, ice packs, and calming the patient are done once epinephrine has been administered.
A patient is receiving penicillin G [Bicillin C-R]. Which assessment should the nurse monitor as an indicator of an undesired effect?

a. Cardiac rhythm
b. Serum sodium level
c. Lung sounds
d. Red blood cell (RBC) count
Answer: a
Penicillin G in high IV doses may cause hyperkalemia, which can result in dysrhythmias or cardiac arrest. Hypernatremia occurs with high IV doses of ticarcillin. Lung sounds and the RBC count are unrelated to the administration of penicillin G.
A nurse should teach a patient to observe for which side effects when taking ampicillin?
a. Skin rash and loose stools
b. Reddened tongue and gums
c. Digit numbness and tingling
d. Bruising and petechiae
Answer: A
Ampicillin's most common side effects are rash and diarrhea; both reactions occur more frequently with ampicillin than with any other penicillin. Reddened tongue and gums, digit numbness and tingling, and bruising and petechiae are not associated side effects of ampicillin.
Both IV ampicillin/sulbactam [Unasyn] and gentamicin are ordered for a patient. When administering these medications, the nurse will do what?

a. Ensure that separate IV solutions are used.
b. Use two different peripheral IV sites.
c. Administer the gentamicin first.
d. There are no necessary precautions.
Answer: A
When penicillins are present in high concentrations, they interact chemically with aminoglycosides, causing inactivation of the aminoglycosides. Therefore, penicillins and aminoglycosides should not be mixed in the same IV solution. Rather, these drugs should be administered separately. Two different peripheral IV sites are not necessary. Administering the gentamicin first does not ensure separation of the two medications.
The nurse identifies which statements about penicillins as true? (Select all that apply.)

a. Penicillins are the safest antibiotics available.
b. The principal adverse effect of penicillins is allergic reaction.
c. A patient who is allergic to penicillin always has a cross-allergy to cephalosporins.
d. A patient who is allergic to penicillin is also allergic to vancomycin, erythromycin, and clindamycin.
e. Penicillins are normally eliminated rapidly by the kidneys but can accumulate to harmful levels if renal function is severely impaired.
Answers: A,B,E
A patient who is allergic to penicillin has a 1% chance of also being allergic to cephalosporins. Patients who are allergic to penicillin are safely able to take vancomycin, erythromycin, and clindamycin. The other three statements are true.
An antimicrobial medication that has selective toxicity has which characteristic?

a. Ability to transfer DNA coding
b. Ability to suppress bacterial resistance
c. Ability to avoid injuring host cells
d. Ability to act against a specific microbe
Answer C
Selective toxicity refers to an antibiotic that has the ability to injure only invading microbes, not the host. Conjugation is the process through which DNA coding for drug resistance is transferred from one bacterium to another. Antibiotics do not suppress bacterial resistance, but rather promote the emergence of drug-resistant microbes. Antibiotics that are narrow spectrum are active against only a few microbes.
The development of a new infection as a result of the elimination of normal flora by an antibiotic is referred to as what?

a. Resistant infection
b. Superinfection
c. Nosocomial infection
d. Allergic reaction
Answer: B
Antibiotic therapy can destroy the normal flora of the body, which normally would inhibit the overgrowth of fungi and yeast. When the normal flora is decreased, these organisms can overgrow and cause a new infection, or superinfection.
The nurse identifies which host factor as the most important when choosing an antimicrobial drug?

a. Age
b. Competent immune function
c. Genetic heritage
d. Previous medication reactions
Answer: B
Two factors—host defenses and the site of infection—are unique to the selection of antibiotics. It is critical for success that antibiotics act synergistically with the immune system to subdue infection. Other host factors, such as age, genetic heritage, and previous drug reactions, are the same factors that must be considered when choosing any other medication.
What is the minimum bactericidal concentration (MBC)?

a. The lowest concentration of an antibiotic needed to suppress bacterial growth completely
b. The lowest concentration of an antibiotic needed to reduce the number of bacterial colonies by 99.9% Correct
c. The lowest concentration of an antibiotic needed to produce effects
d. The lowest dose of an antibiotic needed to eradicate bacteria
Answer: B
The MBC is the lowest concentration of drug that produces a 99.9% decline in the number of bacterial colonies (indicating bacterial kill). The lowest antibiotic concentration needed to suppress bacterial growth or to produce effects and the lowest antibiotic dose needed to eradicate bacteria are incorrect descriptions of MBC.
Which are examples of the improper use of antibiotic therapy? (Select all that apply.)

a. Using surgical drainage as an adjunct to antibiotic therapy
b. Treating a viral infection
c. Basing treatment on sensitivity reports
d. Treating fever in an immunodeficient patient
e. Using dosing that results in a superinfection
Answers: B, E
Common misuses of antibiotics include (1) treatment of a viral infection, which results in exposure of the patient to the risks of the medication without providing any benefits; and (2) improper dosing (dosing that is too high results in superinfection). The other answers are examples of the proper use of antimicrobial therapy.
A nurse should recognize that antibiotic prophylaxis is appropriate in patients with which medical conditions? (Select all that apply.)

a. Aortic valve replacement
b. Ruptured appendix
c. Bronchitis
d. Neutropenia
e. Chickenpox
Answer: A, D
Antibiotic prophylaxis is appropriate and effective in certain situations. These include patients who have prosthetic valves and are at risk for bacterial endocarditis. The use of antibiotics in "dirty" surgeries, such as those for ruptured organs, is considered treatment, not prophylaxis. Severe neutropenia can put patients at risk for severe infection, and antibiotics can reduce infections but may encourage fungal invasion. Antibiotics are not prescribed preventively for bronchitis or chickenpox.
The nurse identifies appropriate use of antimicrobials to prevent infection in which situations? (Select all that apply.)

a. Cardiac surgery
b. Recurrent urinary tract infections in women
c. Anemia
d. Treatment of fever of unknown origin
e. Hysterectomy
Answer: A, B, E
Prophylactic use of antibiotics can reduce the incidence of infection in certain kinds of surgery. Procedures in which prophylactic efficacy has been documented include cardiac surgery, peripheral vascular surgery, orthopedic surgery, and surgery on the gastrointestinal (GI) tract (stomach, duodenum, colon, rectum, and appendix). Prophylaxis is also beneficial for women undergoing a hysterectomy or an emergency cesarean section. Severe neutropenia, not anemia, puts individuals at high risk of infection. In young women with recurrent urinary tract infection, prophylaxis with trimethoprim/sulfamethoxazole may be helpful. Unless the cause of a fever is a proven infection, antibiotics should not be used. Fever by itself constitutes a legitimate indication for antibiotic use only when the fever occurs in a severely immunocompromised person. Because fever may indicate infection and because infection can be lethal to immunocompromised individuals, these patients should be given antibiotics when fever occurs, even if fever is the only indication that an infection may be present.
A nurse is assessing the effects of antimicrobial therapy in a patient with pneumonia. The nurse should establish which outcomes when planning care? (Select all that apply.)

a. Potassium level of 4 mEq/dL
b. Reduction of fever Correct
c. Sterile sputum cultures Correct
d. Oxygen saturation of 98% Correct
e. Elastic skin turgor
Antimicrobial therapy is assessed by monitoring clinical and laboratory responses. Clinical indicators of success in a patient with pneumonia may include afebrile status and resolution of an infectious infiltrate, resulting in an oxygen saturation above 95%. The disappearance of infectious organisms from post-treatment cultures also indicates resolution of infection. Potassium levels and elastic skin turgor are not assessment parameters for clinical infections, including pneumonia.
Which instruction should a nurse include in the discharge teaching for a patient who is to start taking tetracycline?

a. "You may stop taking the pills when you begin to feel better."
b. "Use sunscreen and protective clothing when outdoors."
c. "You'll have to come back to the clinic for weekly blood work."
d. "Take the medication with yogurt or milk so you won't have nausea."
Answer: B
Tetracyclines are bacteriostatic antibiotics; photosensitivity and severe sunburn are common adverse effects. A full course of antibiotics must always be taken. Blood studies are not necessary for therapeutic levels. Absorption decreases after ingestion of chelates, such as calcium and magnesium, so doses should be given 2 hours before or 2 hours after ingestion of milk products
A nurse assessing a patient who is 12 years old should associate which complication with the patient's receiving tetracycline as a younger child?

a. Delay in long bone growth
b. Early onset of puberty
c. Severe face and body acne
d. Discoloration of the teeth
Answer: D
Tetracycline is contraindicated in children younger than 8 years of age, because it binds to calcium in developing teeth, resulting in permanent discoloration of the teeth. Delay in long bone growth, early onset of puberty, and severe face and body acne are not adverse effects associated with tetracyclines.
Which laboratory result should a nurse monitor more frequently when a patient is receiving clarithromycin [Biaxin] and warfarin [Coumadin]?

a. Activated partial thromboplastin time (aPTT)
b. Platelet count
c. Erythrocyte sedimentation rate (ESR)
d. International normalized ratio (INR)
Answer: D
Clarithromycin is a macrolide similar to erythromycin and can inhibit hepatic metabolism of medications such as warfarin and theophylline. The INR is the blood test used to evaluate warfarin ranges. The aPTT is the blood test used in monitoring heparin. The platelet count and ESR are not affected by clarithromycin
Which cardiovascular finding does the nurse identify as a possible adverse effect of erythromycin [Ery-Tab] therapy?

a. Heart rate of 52 beats per minute
b. Prolonged QT interval Correct
c. Jugular vein distention
d. Grade III diastolic murmur
Answer: B
When present in high levels, erythromycin can prolong the QT interval, causing a potentially fatal ventricular dysrhythmia. It should be avoided by patients taking class IA or class III antidysrhythmic medications or others that inhibit metabolism.
What does the nurse identify as an adverse effect of clindamycin [Cleocin] therapy?

a. Cyanosis and gray discoloration of the skin
b. Frequent loose, watery stools with mucus and blood
c. Reduction in all blood cells produced in the bone marrow
d. Elevated bilirubin, with dark urine and jaundice
Answer: B
Clostridium difficile-associated diarrhea (CDAD) is the most severe toxicity associated with clindamycin and is characterized by profuse, watery stools. The cause is superinfection of the bowel with Clostridium difficile, an anaerobic gram-positive bacillus. Gray syndrome, which usually occurs in infants and those with aplastic anemia, is an adverse effect of chloramphenicol [Chloromycetin]. Hepatotoxicity is associated most closely with telithromycin [Ketek].
Which statements about CDAD associated with clindamycin therapy does the nurse identify as true? (Select all that apply.)

a. Leukopenia commonly occurs.
b. It is a potentially fatal condition. Correct
c. Patients usually experience abdominal pain. Correct
d. Anticholinergics are effective in treating the diarrhea.
e. Clindamycin therapy should be discontinued and vancomycin started. Correct
Answer: B, C, E
CDAD is a potentially fatal condition in which patients experience abdominal pain. If CDAD develops, clindamycin therapy should be stopped and vancomycin or metronidazole therapy started. Leukocytosis, not leukopenia, develops. Anticholinergics can make the diarrhea worse and therefore should be avoided.
A nurse is administering a daily dose of tobramycin at 1000. At which time should the nurse obtain the patient's blood sample to determine the trough level?

a. 0800
b. 0900
c. 1130
d. 1200
Answer: B
Trough levels determine the lowest level between doses. Blood is drawn just before the next dose is administered when a divided dose is used or 1 hour before the next dose if a single daily dose is used.
A nurse monitors a patient who is receiving an aminoglycoside (gentamicin) for symptoms of vestibular damage. Which finding should the nurse expect the patient to have first?

a. Unsteadiness
b. Vertigo
c. Headache
d. Dizziness
Answer: C
Gentamicin causes irreversible ototoxicity, which results in both impaired hearing and disruption of balance. Headache is the first sign of impending vestibular damage (balance) and may last 1 to 2 days. Unsteadiness, vertigo, and dizziness appear after headache.
When administering an aminoglycoside to a patient with myasthenia gravis, it is most important for the nurse to assess what?

a. Deep tendon reflexes
b. Breath sounds
c. Eyelid movement
d. Muscle strength
Answer: B
Aminoglycosides can inhibit neuromuscular transmission, causing potentially fatal respiratory depression. Patients with myasthenia gravis (MG) are at an increased risk. Deep tendon reflexes, eyelid movement, and muscle strength are important assessments for a patient who has MG, but they are not as important as airway and breathing ability.
Before administering an aminoglycoside, it is most important for the nurse to assess the patient for a history of what?

a. Myasthenia gravis
b. Asthma
c. Hypertension
d. Diabetes mellitus
Answer: A
Aminoglycosides can inhibit neuromuscular transmission, causing flaccid paralysis and potentially fatal respiratory depression. These drugs should be used with extreme caution in patients with myasthenia gravis.
Which statements about ototoxicity and aminoglycosides does the nurse identify as true? (Select all that apply.)

a. The risk of ototoxicity is related primarily to excessive peak levels.
b. The first sign of impending cochlear damage is headache.
c. The first sign of impending vestibular damage is headache. Correct
d. Ototoxicity is largely irreversible. Correct
e. Use of aminoglycosides for less than 10 days is recommended to avoid ototoxicity. Correct
Answer: C, D, E
The risk of ototoxicity with aminoglycoside use is related primarily to excessive trough levels. The first sign of impending vestibular damage is headache. The first sign of cochlear damage is tinnitus. The other two statements are true.
The nurse is assessing a patient who is receiving a sulfonamide for treatment of a urinary tract infection. To monitor the patient for the most severe response to sulfonamide therapy, the nurse will assess for what?

a. Diarrhea
b. Skin rash and lesions
c. Hypertension
d. Bleeding
Ans: B

The nurse's priority is to monitor for hypersensitivity reactions. The most serious response to sulfonamide therapy is Stevens-Johnson syndrome, which manifests as symptoms of the skin and mucous membranes, lesions, fever, and malaise. In rare cases, hematologic effects occur, requiring periodic blood studies.
When providing patient teaching for oral sulfonamide therapy, the nurse should instruct the patient to take the sulfonamide in what way?

a. At mealtime, when food is available
b. With soy or nonmilk products
c. Between meals with a full cup of water
d. On awakening before breakfast
Ans: D
Oral sulfonamides should be taken on an empty stomach and with a full glass of water. To minimize the risk of renal damage, adults should maintain a daily urine output of 1200 mL. Sulfonamides should not be taken with soy or nonmilk products or food or before breakfast without liquids.
Before administering trimethoprim, it is most important for the nurse to assess the patient for a history of what?

a. Heart failure
b. Alcoholism
c. Diabetes
d. Emphysema
Ans: B
Trimethoprim inhibits bacterial synthesis of folic acid. It is avoided in patients when folate deficiency is likely, such as in alcoholism, because bone marrow suppression may occur. Heart failure, diabetes, and emphysema are unrelated to adverse effects with trimethoprim.
The nurse identifies which statements about Stevens-Johnson syndrome as true? (Select all that apply.)

a. Patients with Stevens-Johnson syndrome have a mortality rate of about 25%. Correct
b. Toxemia is associated with Stevens-Johnson syndrome. Correct
c. Short-acting sulfonamides do not induce Stevens-Johnson syndrome.
d. Patients with Stevens-Johnson syndrome usually are hypothermic.
e. Lesions of the mucous membranes are a characteristic of Stevens-Johnson syndrome.
AND: A, B, E
Short-acting sulfonamides do induce Stevens-Johnson syndrome on rare occasions, and patients with Stevens-Johnson syndrome usually are hyperthermic. The other three statements are true.
A nurse observes a red streak and palpates the vein as hard and cordlike at the intravenous (IV) site of a patient receiving cefepime [Maxipime]. Which assessment should the nurse make about the IV site?
1.An allergic reaction has developed to the drug solution.
2.The drug has infiltrated the extravascular tissues.
3. Phlebitis of the vein used for the antibiotic has developed.
4. Local infection from bacterial contamination has occurred.
3.
A patient develops flushing, rash, and pruritus during an IV infusion of vancomycin [Vancocin]. Which action should a nurse take?
1.Reduce the infusion rate.
2.Administer diphenhydramine [Benadryl].
3.Change the IV tubing.
4.Check the patency of the IV.
1.
A patient who is receiving vancomycin [Vancocin] IV for a methicillin-resistant Staphylococcus aureus (MRSA) infection asks a nurse, "Why can't I take this medicine in a pill?" Which response should the nurse make?
1. "The prescription could be changed, because vancomycin comes in two forms."
2. "You're allergic to penicillin, and this is the only way this medication can be given."
3. "It will cause too much loss of appetite and nausea if given in the oral form."
4. "It is more effective by IV, because the pill form will stay in the digestive tract."
4.
A patient who is receiving ceftriaxone has all of these medications ordered. The nurse monitors the patient for an adverse effect related to an interaction with which medication?
1.Regular insulin
2.Ampicillin [Polycillin]
3. Naproxen [Naprosyn]
4.Bisacodyl [Dulcolax]
3.
A patient is receiving vancomycin [Vancocin]. The nurse identifies what as the most common toxic effect of vancomycin therapy?
1.Ototoxicity
2.Hepatotoxicity
3.Renal toxicity
4.Cardiac toxicity
3.
Before administering a cephalosporin to a patient, it is most important for the nurse to assess the patient for an allergy history to what?
1.Soy products
2.Peanuts
3.Penicillins
4.Opioids
3.
It is most important for the nurse to assess a patient receiving a cephalosporin for the development of which manifestation of antibiotic-associated pseudomembranous colitis (AAPMC)?
1. Rigidity
2. Ileus
3. Ascites
4. Diarrhea
4.
When ceftriaxone is administered intravenously, it is most important for the nurse to avoid mixing it with what?
1.Ringer's lactate
2.Normal saline
3.Sterile water
4.D5 0.45% NS
1.
Which statements about vancomycin [Vancocin] does the nurse identify as true? (Select all that apply.)
1.Vancomycin is the most widely used antibiotic in U.S. hospitals.
2. Vancomycin is effective in the treatment of Clostridium difficile infection.
3. Vancomycin is effective in the treatment of MRSA infections.
4. Patients who are allergic to penicillin are also allergic to vancomycin.
5.The major toxicity of vancomycin therapy is liver failure.
1.2.3.
Which instructions will the nurse include when teaching a patient about cephalosporin therapy? (Select all that apply.)
1. "Notify your healthcare provider if you develop diarrhea."
2. "Take aspirin if you develop a headache."
3. "Notify your healthcare provider if you develop a rash."
4. "Cephalosporins may not be taken with food."
5."Do not take cephalosporins if you have lactose intolerance."
1.3.
Vancomycin
What agent is in the glycopeptide drug class?
PO, IV
What are the routes of administration for vancomycin?
MRSA & Clostridium difficile
Vancomycin is the drug of choice for which pathogens?
Clostridium difficile
What is the clinical use for PO vancomycin?
Gram-positive aerobes (IV only) & anaerobes (PO only)
What is the antimicrobial spectrum for vancomycin?
MSSA
MRSA
Streptococcus sp. including S. pneumoniae
Enterococcus faecalis
Which gram-positive aerobes do vancomycin cover?
Clostridium difficile
Which gram-positive anaerobe does vancomycin cover?
Cell wall synthesis inhibitor (binds D-Ala-D-Ala terminus, prevents peptidoglycan-linking, stable cell wall cannot be formed)
What is the mechanism of action of vancomycin?
AUC/MIC-dependent, Bactericidal
What are the pharmacodynamics of vancomycin?
Yes (routinely used)
Is vancomycin safe in pregnancy & lactation?
Yes
Is vancomycin safe in children & neonates?
Caution with renal function
Is vancomycin safe in the elderly?
Caution with accumulation of drug
Is vancomycin safe in obesity?
Pneumonia, skin & soft tissue infections, endocarditis, osteomyelitis, etc.
What are the clinical uses of vancomycin?
Poor, <5% (used to treat GI infections)
What is the PO absorption for vancomycin?
Good
What is the distribution of vancomycin in serum, skin/tissues, & body fluids?
Moderate
What is the distribution of vancomycin in the CSF?
Minimal
What is the metabolism of vancomycin?
Urine, 80-90% of unchanged drug
How is vancomycin excreted?
Red Man's Syndrome (infusion related) & Nephrotoxicity (15-20% of patients)
What are the two major side effects of vancomycin?
NSAIDs, IV contrast dye, & hypertensive agents (specifically ACE inhibitors)
What non-antimicrobials can cause acute kidney injury with vancomycin?
Serum creatinine (SCr)
What lab must be ordered to monitor acute kidney injury with vancomycin?
Enterococcus faecium (~70$ are VRE)
Staphylococcus aureus, MRSA
Coagulase-negative Staphylococcus sp. (Staphylococcus epidermis)
Which pathogens have resistance issues with vancomycin?
penicillin
Vancomycin can be used in gram-positive infections in _______________-allergic patients
Vancomycin
a glycopeptide antibiotic that is primarily active against gram (+) bacteria.
The nurse understands that PO vancomycin is typically indicated for...
Tx of staph. enterocolitis and antibiotic-associated pseudomembranous colitis due to C. difficile
With regards to PO vancomycin, the nurse knows that...
PO vancomycin is NOT systemically absorbed but is instead excreted in the feces
Unlike PO vanco, the nurse can expect for IV vancomycin to be given for...
MRSA; severe infections due to septicemia; bone, skin, lower RT infections unresponsive to antibiotics
A patient dx w/ MSSA is ordered to receive IV vancomycin. The nurse knows that this order is questionable because...
MSSA is not tx w/ vanco... rather it's tx w/ penicillin based antibiotics
After seeing that IV vanco is mostly renally cleared through urine, it is important for the nurse to...
Assess renal function (BUN, creatinine) for any renal dysfunction. Renal dosing based on GFR would be needed for renal dosing, assess that p/t can actually urinate 30-60 mL/hr and is NOT anuric
For patients on IV vancomycin, the nurse knows that it is important to
draw and check serum peak and trough vanco levels. This is done to ensure that the vanco is ACTUALLY being cleared. Common practice to check vanco trough after 4th dose to ensure it's being cleared
Because vanco is known to be nephrotoxic, what should the nurse assess prior and during admin?
I&O, specifically U/O to ensure it's 30-60 mL/hr; BUN, creatinine to assess for renal status; GFR for renal dosing, serum Na
"Red Man" syndrome
Vascular dilatation, skin flushing of head, neck, & upper body, rash caused by a rapid IV infusion of IV vanco. Caused b/c vanco has some effect on histamine release
The nurse knows that "Red Man" syndrome secondary to rapid IV infusion of Vanco is NOT an allergic rxn because...
once you slow down IV vanco infusion rate, the flushing/redness/rash goes away
Because of "Red Man" syndrome + very high potential for nephrotoxicity, ototoxicity, and hypoTN w/ IV vanco, the nurse knows that this can all be prevented by...
diluting 500mg IV vanco in 100 mL of IVF or 750-1000 mg IV vanco in 250 mL of IVF and infusing over 60-120 min at a rate of 10 mg/min for AT LEAST 60 minutes
A patient on IV vanco for about 1 week has decreased WBCs on labs. The nurse knows that this is...
neutropenia r/t prologned IV vanco use. This can actually be reversed by d/c the IV vanco
Stevens-Johnson syndrome
a really scary derm condition that can be caused by IV vanco. Rarely ever seen before, but once it happens it's devastating. Clasically associated w/ vanco and anti-epileptic drugs
VRE
Bac that's resistant to vanco.
A patient that recently had C&S drawn revealed that he has VRE. Knowing this, the nurse can anticipate to administer...
Quinupristin/dalfopristin (Synercid) or Linezolid (Zyvox)
For a pt w/ IV vanco, other than setting an appropriate SLOW infusion rate and running the infusion for at least 60 minutes, what other assessments should the nurse include when caring for this pt?
IV site assessment for patency, redness, phlebitis, or extravasation of the vanco. Infiltration of vanco = super caustic to underlying tissue, might need surgery if enough was infused to the point where it causes tissue necrosis. IV site should also be rotated
A patient has been ordered for IV vanco but has never gotten a C&S drawn. The nurse knows that C&S = VERY important prior to vanco admin because...
Vanco is NOT appropriate for all infections... you don't want to give vanco to someone who doesn't need it (e.g. VRE, MSSA)
The nurse should monitor for diarrhea that's persistent and watery in pts on vanco and other antibiotics in general due to...
the risk for a superimposing C. diff pseudomembranous colitis that comes w/ antibiotic use. The vanco/antibiotic wipes out the healthy microflora of the gut causing C. diff to be RAMPANT when it normally isn't
The nurse knows that vanco should be used in caution in what kinds of women?
Women nursing babies
Why is it important for the nurse to assess v/s, esp BP, during vanco infusion?
B/c too fast of a vanco infusion can cause hypoTN (due to vanco's effect on histamine). Monitor for hypoTN w/ compensatory tachy
The nurse knows that vanco is contraindicated in...
MSSA, VRE, anaphylactic non-red man syndrome hypersensitivity to vanco, corn product allergy
The nurse is aware that caution should be taken in patients on which of the following known ototoxic drugs?
NSAIDS (aspirin, Ibuprofen - Motrin & Advil), Loop diuretics (furosemide)
Other antibiotics are _______, and the nurse should be cautious when administering antibiotic to them
nephrotoxic
Glycopeptide mechanism of action?
Inhibit cell wall synthesis
Glycopeptide mode of action?
Bactericidal
Glycopeptides are ineffective aganist what?
Vanco- resistant bacteria such as Entercocci (VREF)
Glycopeptide drugs?
Vancomycin
Glycopeptide Spectrum of activity?
Gram+
Glycopeptide route of admin.
Oral and IV
Glycopeptides Treat?
-Serious infections: Bone, skin , lower resp. septicema
-MRSA
- S.aureus
-C.diff
Glycopeptides Drug Interactions?
-When taken with Furosemide (diuretic), aminoglycosides, colistin, cyclosporine it increase oto, nephro, toxicity
- Oral absorption of vancomycin decreases cholestryamine, and colestipol
What drug masks the toxicity when taken with vancomycin?
Dimenhydrinate
Glycopeptides side effects/adverse rxn.
Redman syndrome
Ototoxicity
Nephrotoxcity
Blood dycrasias
Steve-Jo syndr.
Psuedomembranous colitis
Redman syndrome occurs from?
Causes?
IV administered too fast
Hypotension
Red neck, face, and chest
Glycopeptides Nursing Interventions
-Refer to MEDICATE
-Mointor Vanco levels
-Admins over 1-2 hours
- Monitor BP/ IV site
-Monitor Renal/ Hearing
- Rotate IV site
Glyocopeptides use what test to access renal impairment?
Why?
Glomuleral filtration rate or Urine output.
Quicker then BUN and creatine clearance
Types of aminoglycosides
Amikacin, Gentimicin, Kanamycin, Neomycin, Paromomycin, streptomycin, tobramycin
Aminoglycosides mechanism of action
- narrow- spectrum antibiotics
- disrupt protein synthesis and cause rapid bacterial death
Therapeutic uses of aminoglycosides
- used primarily against aerobic gram- negative bacilli
- oral therapy: suppression of bowel flora before colorectal surgery
- topical therapy: treatment of local infections of the eyes, ears, and skin
True/ false
aminoglycosides are absorbed by the GI tract
false
Amino glycosides are eliminated by the _______.
kidneys
Adverse effects of aminoglycosides
- ototoxicity
- nephrotoxicity
Ototoxicity of aminoglycosides
- can cause irreversible injury to sensory cells of the inner ears, resulting in hearing loss and disturbed balance
- ototoxicity is related to persistently elevated drug levels
Same aminoglycoside dose can produce different plasma levels in different patients
- peak levels must be high enough to cause bacterial kill
- trough levels must be low enough to minimize toxicity to the inner ears and kidneys
Aminoglycosides kill bacteria so their action is ______________.
bactericidal
Amino glycosides are highly polar polycations and therefore cannot enter the ______.
CSF
Aminoglycosides are rapidly excreted by the __________.
Kidneys
Aminoglycosides are ___________- spectrum antibiotics
narrow
Amino glycosides are primarily used to treat serious infections with aerobic gram- _____________ bacilli.
negative
Amino glycosides can be toxic to the _________ and __________ _____.
kidneys, inner ear
Amino glycosides can kill bacteria for several ________ after serum levels drop below the MBC.
hours
The principal cause of bacterial resistance is production of _____________ that can inactivate aminoglycosides.
enzymes
Aminoglycosides cannot kill ____________.
anaerobes
Major adverse effects of amioglycoside antibiotics include damage to (select all that apply)

a. cochlear
b. heart
c. kidneys
d. lungs
e. stomach
f. vestibular apparatus
a. cochlear
c. kidneys
f. vestibular apparatus
Facultative bacteria survive in what condition?

a. anaerobic
b. both anaerobic and aerobic
c. aerobic
b. both anaerobic and aerobic
A patient who is prescribed tobramycin (Nebcin) complains of a headache. What is the priority nursing action?

a. Assess the onset, characteristics, and associated symptoms of the headache
b. Medicate with acetaminophen and reassess in 1 hour
c. Withhold the tobramycin and notify the prescriber when making rounds
d. Withhold the tobramycin and notify the prescriber STAT
a. Assess the onset, characteristics, and associated symptoms of the headache
The nurse is assessing a patient who is scheduled to received a dose of gentamicin (Garamycin). In the last 12 hours, fluid intake has been 900 mL, urine output has been 300 mL, and the patient's bladder is not distended. What should the nurse do?

A. Administer the drug.
B. Administer the drug and notify the prescriber of the output.
C. Instruct the patient to drink a full glass of water each time the medication is administered.
D. Withhold the drug and notify the prescriber of the output.
D. Withhold the drug and notify the prescriber of the output.
The nurse is taking a history from the spouse of a patient who was admitted in a septic state and prescribed aminoglycoside antibiotic. Which question is most important to ask the patient's spouse about the patient's history.

A. "Has your spouse every had any surgery performed?"
B. "Has your spouse been told to follow any specific diet?"
C. "Has your spouse received a flu vaccine this year?"
D. "What medications is your spouse currently taking?"
D. "What medications is your spouse currently taking?"
The nurse is assessing for adverse effects of IV tobramycin. Which change would be a priority to report to the prescriber?

A. Dilute urine.
B. Headache.
C. Limp, weak muscles.
D. Ringing in the ears.
C. Limp, weak muscles.
The nurse is aware that the risk of ototoxicity is significantly increased if a hypertensive patient is also receiving which medication?

A. Bumetanide.
B. Ethacyrnic acid.
C. Furosemide.
D. Hydrochlorothiazide.
B. Ethacyrnic acid.
What is the priority nursing action before administering an aminoglycoside to a patient with an eGFR of 50 mL/min?

A. Ask the patient if he or she has had a headache.
B. Assess peak levels of the drug.
C. Assess liver function tests.
D. Compare prescribed dose to recommended dose.
D. Compare prescribed dose to recommended dose.
When ahminoglycosides are prescribed IV as a once-daily dose, it is important to monitor trough levels:

A. 30 minutes before the next dose.
B. 1 hour after completing the infusion.
C. 1 hour before the next dose.
D. 30 minutes after completing the infusion.
C. 1 hour before the next dose.
The nurse is caring for a patient who is receiving gentamicin twice a day. Peak and trough levels were drawn after the fourth dose. Results were peak 3 mcg/mL and trough 0.6 mcg/mL. What should the nurse do?

A. Administer an additional dose.
B. Continue nursing care.
C. Consult with the prescriber.
D. Withhold future doses until the prescriber can be consulted.
B. Continue nursing care.
Which of these laboratory tests would be a priority for the nurse to assess when a patient is receiving an amino glycoside?

A. Creatinine.
B. Fasting blood glucose.
C. Hemoglobin and hematocrit.
D. INR.
A. Creatinine.
A patient received a neuromuscular blocking agent during surgery. In the postanesthesia care unit, the prescriber order gentamicin 40 mg IV STAT. What is the most appropriate nursing action?

A. Administer the drug as quickly as possible.
B. Assess the patient's vital signs.
C. Clarify the order.
D. Refuse to administer the drug.
C. Clarify the order.
Aminoglycosides
- tobramycin, gentamycin, neomycin, amikacin, streptomycin*
- used for serious gram - infections, give parenterally for systemic use, *generally restricted to TB treatment
- neomycin is PO and topical, streptomycin is PO, IM, or IV onsets rapid
who is aminoglycosides contraindicated for? interactions?
- contraindicated for those with renal disease, hearing impairment, or pregnant
- interactions; increased risk of ototoxicity with loop diuretics, increased risk of nephrotoxicity with furosemide
aminoglycoside side effects and AE?
- side effects; confusion, numbness, N&V, depression, vertigo
- AE; seizures, ototoxicity, nephrotoxicity, renal failure, anaphylaxis; can cause irreversible nephro and ototoxicity, need baseline hearing test, poorly absorbed in GI tract
nursing interventions for aminoglycosides? teaching?
- monitor peak and trough levels, BUN and creatinine, must increase fluids to 1500-2,000 mL/day, I&O, daily weight
- teach to report headache or dizziness, drink fluids!
Antibacterial/Antiprotozoal
- metrondiazole/flagyl
- used for h-pylori/GI tract disorders, UTI, septicemia, meningitis
- PO, IV, topical
- 2 hours onset but IVs rapid onset
- acts on both bacteria and protozoa (parasites)
antibacterial/antiprotozoals contraindicated in..? interactions?
- hypersensitivity, pregnancy, and hepatic disease
- avoid alcohol and alcohol containing meds for 48 hours after treatment's complete
side effects of antibacterial/antiprotozoals?
- dark reddish brown urine, N&V, metallic or bitter taste, headache, depression, insomnia, dizzy, irritable
- AE; thrombophlebitis, bone marrow suppression, neurotoxicity
nursing interventions for antibacterial/antiprotozoals?
- monitor urine output and color changes
- assess ECG and neuro changes during medication administration
-proper handwashing and hygiene after bowel cleansing
client teaching for antibacterial/antiprotozoals?
- DO NOT use alcohol or meds with alcohol for 48 hours after treatments complete
- teach that urine may be dark/reddish brown in color
- may have metallic or bitter taste in mouth
- teach proper hygiene w bowel movements
Antibiotics; Vancomycin
- DOC for MRSA, cellulitis, bone infections, colitis, meningitis
- PO or IV
- rapid onset
- best for severe gram + infections
Contraindications for antibiotic vancomycin? interactions?
- contraindicated for hypersensitivity, pregnancy, and renal disease
- interacts with some vitamins and herbal products, avoid use when on amikacin, gentamicin, or streptomycin
side effects of antibiotic vancomycin?
- dry mouth, diarrhea, abdominal cramping, headache, hypotension, flushing, tachycardia, N&V, muscle cramps, tachycardia
adverse effects of vancomycin?
- bloody urine = nephrotoxicity
- loss of hearing = ototoxicity
- anaphylaxis
nursing interventions for vancomycin?
- monitor peaks and troughs
- infuse over at least 60 minutes on infusion pump
- monitor BUN and creatinine
- increase fluids 1500-2000 mL/day
- I&O, daily weight
- baseline hearing tests needed
pt teaching for vancomycin?
- teach to report headache or dizziness, drink adequate fluids
- report bloody urine, dizziness, ringing in the ears or loss of hearing
A patient has a Pseudomonas aeruginosa infection that is sensitive to aminoglycosides, and the prescriber orders gentamicin. The patient tells the nurse that a friend received amikacin [Amikin] for a similar infection and wonders why amikacin was not ordered. What will the nurse tell the patient?
a. "Amikacin is given when infectious agents are resistant to other aminoglycosides."
b. "Amikacin is more vulnerable to inactivation by bacterial enzymes."
c. "Amikacin is a narrow-spectrum drug and will probably not work for this
infection."
d. "Gentamicin is less toxic to the ears and the kidneys."
ANS: A
Resistance to amikacin is uncommon at this point; to minimize the emergence of amikacin- resistant bacteria, this drug is reserved for infections in which resistance to other aminoglycosides has developed. Amikacin is the least susceptible to inactivation by bacterial enzymes. Amikacin is a broad-spectrum antibiotic. All aminoglycosides are ototoxic and nephrotoxic.
A patient is diagnosed with an infection caused by Staphylococcus aureus, and the prescriber orders intravenous gentamicin and penicillin (PCN). Both drugs will be given twice daily. What will the nurse do?
a. Administer gentamicin, flush the line, and then give the penicillin.
b. Give the gentamicin intravenously and the penicillin intramuscularly.
c. Infuse the gentamicin and the penicillin together to prevent fluid overload.
d. Request an order to change the penicillin to vancomycin.
ANS: A
Gentamicin should not be infused with penicillins in the same solution, because PCN inactivates gentamicin; therefore, the nurse should give one first, flush the line, and then give the other. The nurse cannot give a drug IM when it is ordered IV without an order from the prescriber. These two drugs should not be infused in the same solution. There is no indication for changing the PCN to vancomycin; that should be done for serious infections.
A nurse is reviewing the culture results of a patient receiving an aminoglycoside. The report reveals an anaerobic organism as the cause of infection. What will the nurse do?
a. Contact the provider to discuss an increased risk of aminoglycoside toxicity.
b. Continue giving the aminoglycoside as ordered.
c. Request an order for a different class of antibiotic.
d. Suggest adding a penicillin to the patient's drug regimen.
ANS: C
Aminoglycosides are not effective against anaerobic microbes, so another class of antibiotics is indicated. There is no associated increase in aminoglycoside toxicity with anaerobic infection. The aminoglycoside will not be effective, so continuing to administer this drug is not indicated. Adding another antibiotic is not useful, because the aminoglycoside is not necessary.
A patient is diagnosed with a lung infection caused by P. aeruginosa. The culture and sensitivity report shows sensitivity to all aminoglycosides. The nurse knows that the rate of resistance to gentamicin is common in this hospital. The nurse will expect the provider to order which medication?
a. Amikacin [Amikin]
b. Gentamicin
c. Paromomycin
d. Tobramycin
ANS: A
When resistance to gentamicin and tobramycin is common, amikacin is the drug of choice for initial treatment of aminoglycoside-sensitive infections. Gentamicin would not be indicated, because resistance is more likely to develop. Paromomycin is used only for local effects within the intestine and is given orally. Tobramycin is not indicated, because organisms can more readily develop resistance.
A nurse preparing to administer intravenous gentamicin to a patient notes that the dose is half the usual dose for an adult. The nurse suspects that this is because this patient has a history of:
a. antibiotic resistance.
b. interpatient variation.
c. liver disease.
d. renal disease.
ANS: D
The aminoglycosides are eliminated primarily by the kidneys, so in patients with renal disease, doses should be reduced or the dosing interval should be increased to prevent toxicity. Patients with antibiotic resistance would be given amikacin. Interpatient variation may occur but cannot be known without knowing current drug levels. Aminoglycosides are not metabolized by the liver, so liver disease would not affect drug levels.
A patient is admitted to the unit for treatment for an infection. The patient receives IV amikacin [Amikin] twice a day. When planning for obtaining a peak aminoglycoside level, when should the nurse see that the blood is drawn?
a. 30 minutes after the IV infusion is complete
b. 1 hour after the IV infusion is complete
c. 1 hour before administration of the IV infusion
d. A peak level is not indicated with twice-daily dosing.
ANS: A
When divided daily doses are used, blood samples for measurement of peak levels are drawn 1 hour after IM injection and 30 minutes after completion of an IV infusion. This medication is administered IV, so blood draws must follow 30 minutes after infusion to obtain peak levels. Measurement of peak levels is unnecessary only when a single daily dose is used.
A patient who has been receiving intravenous gentamicin for several days reports having had a headache for 2 days. The nurse will request an order to:
a. discontinue the gentamicin.
b. obtain a gentamicin trough before the next dose is given
c. give an analgesic to control headache discomfort.
d. obtain renal function tests to evaluate for potential nephrotoxicity.
ANS: A
A persistent headache may be a sign of developing ototoxicity, and since ototoxicity is largely irreversible, gentamicin should be withdrawn at the first sign of developing ototoxicity. A gentamicin trough should be obtained before the next dose is given when high gentamicin levels are suspects. Analgesics are not indicated until a serious cause of the headache has been ruled out. A headache is an early sign of ototoxicity, not nephrotoxicity.
A patient who has been taking gentamicin for 5 days reports a headache and dizziness. What will the nurse do?
a. Request an order for a gentamicin peak level.
b. Suspect ototoxicity and notify the prescriber.
c. Tell the patient to ask for help with ambulation.
d. Tell the patient to report any tinnitus.
ANS: B
Headache and dizziness are signs of ototoxicity, and the prescriber should be notified. A peak level is not indicated; it is more important to know the trough level. Telling the patient to ask for help with ambulation and to report tinnitus should both be done but neither one is the priority nursing action.
A patient who takes the loop diuretic ethacrynic acid is given intravenous gentamicin for an infection. After several days of treatment with gentamicin, the nurse reviews the patient's most recent laboratory results and notes a gentamicin trough of 2.1 mcg/mL and normal blood urea nitrogen (BUN) and serum creatinine levels. The nurse will question the patient about:
a. gastrointestinal (GI) symptoms.
b. headache, dizziness, or vertigo.
c. presence of rash.
d. urine output.
ANS: B
Ethacrynic acid has ototoxic properties, and patients who take this drug with an aminoglycoside have an increased risk of ototoxicity, especially when trough levels of the aminoglycoside are elevated. A trough level of 2.1 mcg/mL is above normal limits for gentamicin, so this patient should be asked about early signs of ototoxicity. There is no indication to evaluate for GI symptoms, rash, or urine output.
A patient is receiving an intraperitoneal aminoglycoside during surgery. To reverse a serious side effect of this drug, the nurse may expect to administer which agent?
a. Amphotericin B
b. Calcium gluconate
c. Neuromuscular blocker
d. Vancomycin
ANS: B
Aminoglycosides can inhibit neuromuscular transmission, especially during intraperitoneal or intrapleural instillation, and this risk is increased when neuromuscular blocking agents and general anesthetics are given. Calcium can reverse neuromuscular blockade. Amphotericin B, additional neuromuscular blockers, and vancomycin are not indicated.
A patient shows signs and symptoms of conjunctivitis. Which aminoglycoside would the nurse expect to be ordered?
a. Amikacin [Amikin]
b. Kanamycin [Kantrex]
c. Neomycin [Neomycin]
d. Paromomycin [Humatin]
ANS: C
Neomycin is used for topical treatment of infections of the eye, ear, and skin. Amikacin, kanamycin, and paromomycin are not topical treatments and are not indicated for eye infections.
A nurse is explaining to nursing students why a cephalosporin is used in conjunction with an aminoglycoside for a patient with an infection. Which statement by a student indicates understanding of the teaching?
a. "Cephalosporins enhance the actions of aminoglycosides by weakening bacterial
cell walls."
b. "Cephalosporins prevent neuromuscular blockade associated with
aminoglycosides."
c. "Cephalosporins prolong the postantibiotic effects of the aminoglycosides so doses
can be decreased."
d. "Cephalosporins reduce bacterial resistance to aminoglycosides."
ANS: A
Cephalosporins, penicillins, and vancomycin can be used in conjunction with aminoglycosides; these drugs weaken the bacterial cell wall and enhance the bactericidal actions of aminoglycosides. Cephalosporins do not prevent neuromuscular blockade. They do not prolong the postantibiotic effects of aminoglycosides. They do not affect bacterial resistance.
A patient who is taking gentamicin and a cephalosporin for a postoperative infection requests medication for mild postsurgical pain. The nurse will expect to administer which of the following medications?
a. Acetaminophen
b. Aspirin
c. Ibuprofen d. Morphine
ANS: A
Gentamicin and cephalosporins are both nephrotoxic. This patient should avoid taking other potentially nephrotoxic drugs. Acetaminophen is not nephrotoxic and may be given for mild pain. Aspirin and ibuprofen are both nephrotoxic. Morphine is not nephrotoxic but is not indicated for mild pain.
A patient is receiving gentamicin once daily. A nursing student asks the nurse how the drug can be effective if given only once a day. The nurse explains drug dosing schedules for aminoglycosides. Which statement by the student indicates a need for further teaching?
a. "Gentamicin has a longer half-life than other aminoglycosides."
b. "Large doses given once daily yield higher peak levels."
c. "The postantibiotic effect lasts for several hours."
d. "There is less risk of ototoxicity and nephrotoxicity with large daily doses."
ANS: A
When a daily dose is given once daily instead of divided into 2 or 3 doses, a higher peak level can be achieved. The higher peak, along with the fact that aminoglycosides have a postantibiotic effect, means that the bacterial kill is just as great with one dose as with 2 or 3 doses per day. When a single daily dose is given, the risk of toxicity is reduced. Gentamicin does not have a longer half-life than other aminoglycosides.
A nurse is preparing to administer a dose of gentamicin to a patient who is receiving the drug 3 times daily. The nurse will monitor ____ levels.
a. peak
b. peak and trough
c. serum drug
d. trough
ANS: B
When divided doses of aminoglycosides are given, it is important to measure both peak and trough levels of the drug, because it is more difficult to achieve therapeutic peaks in lower doses without causing toxicity. Trough levels are drawn when single-dosing regimens are used, because high peak levels are guaranteed.
A patient is receiving tobramycin 3 times daily. The provider has ordered a trough level with
the 8:00 AM dose. The nurse will ensure that the level is drawn at what time?
a. 4:00 AM
b. 7:00 AM
c. 7:45 AM
d. 8:45 AM
ANS: C
When a patient is receiving divided doses of an aminoglycoside, the trough level should be drawn just before the next dose; therefore, 7:45 AM would be the appropriate time. It would not be appropriate to draw a trough at the other times listed.
A patient is receiving tobramycin three times daily. A tobramycin peak level is 4.5 and the trough is 1.2. What will the nurse do?
a. Give the next dose as ordered.
b. Hold the next dose and notify the provider.
c. Monitor the patient for signs of nephrotoxicity.
d. Tell the patient to report tinnitus.
ANS: A
These levels are within normal limits, so the next dose may be given safely. It is not necessary to withhold the next dose. These levels do not indicate any increased risk of nephrotoxicity or ototoxicity.


Levels for gentamicin and tobramycin
therapeutic level 4-10
safe trough level 1-2

amikamycin
Thera- 15-30
safe trough 5-10
3. A patient with malaise has been taking daptomycin (Cubicin) for an infection and is concurrently taking simvastatin (Zocor). The nurse should be concerned if the patient complains of:
a.
nausea.
b.
tiredness.
c.
muscle pain.
d.
headache.
ANS: C
Statins can injure muscle tissue, causing muscle aches and pain known as myopathy/rhabdomyolysis. Daptomycin also can cause myopathy and therefore should be used with caution in patients concurrently taking simvastatin. Nausea, tiredness, and headache would not cause the nurse as much concern as the likelihood of myopathy.

DIF: Cognitive Level: Analysis
REF: HMG-CoA Reductase Inhibitors (Statins) | Adverse Effects | Myopathy | Rhabdomyolysis
TOP: Nursing Process: Assessment
MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies
6. The nurse is reviewing the medication orders for a patient who will be receiving gentamicin therapy. Which other medication or medication class, if ordered, would be a potential interaction concern?
a.
Calcium channel blockers
b.
Phenytoin
c.
Proton pump inhibitors
d.
Loop diuretics
ANS: D
Concurrent use of aminoglycosides, such as gentamicin, with loop diuretics increases the risk for ototoxicity. The other drugs and drug classes do not cause interactions.

DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 627
TOP: NURSING PROCESS: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
7. A patient is taking gentamicin (Garamycin) and furosemide (Lasix). The nurse should counsel this patient to report which symptom?
a.
Frequent nocturia
b.
Headaches
c.
Ringing in the ears
d.
Urinary retention
ANS: C
Patients taking furosemide should be advised that the risk of furosemide-induced hearing loss can be increased when other ototoxic drugs, such as gentamicin, are also taken. Patients should be told to report tinnitus or dizziness or hearing loss. Nocturia may be an expected effect of furosemide. Headaches are not likely to occur with concomitant use of gentamicin and furosemide. Urinary retention is not an expected side effect.

DIF: Cognitive Level: Application
REF: High-Ceiling (Loop) Diuretics | Furosemide | Drug Interactions
TOP: Nursing Process: Implementation
MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential
12. A patient with mitral valve prolapse is admitted for a scheduled cystoscopy. The physician has ordered gentamicin to be taken before the procedure. What is the rationale for this?
A) Prevent bacterial endocarditis
B) Prevent inflammation of the urethra
C) Avoid antibiotic use during the procedure D) Decrease need for surgical asepsis
Ans: A
4. A young, nonpregnant female patient with a history of a previous urinary tract infection is experiencing dysuria, urinary urgency and frequency, and suprapubic pain of 3 days' duration. She is afebrile. A urine culture is positive for more than 100,000/mL of urine. The nurse caring for this patient knows that which treatment is most effective?
a.
A 14-day course of amoxicillin with clavulanic acid (Augmentin)
b.
A 7-day course of ciprofloxacin (Cipro)
c.
A single dose of fosfomycin (Monural)
d.
A 3-day course of trimethoprim/sulfamethoxazole (Bactrim)
ANS: D
Short-course therapy is recommended for uncomplicated, community-acquired lower urinary tract infections. The short course is more effective than a single dose, and compared with longer course therapies, it is less costly, has fewer side effects, and is more likely to foster compliance. Amoxicillin with clavulanic acid is a second-line drug used for pyelonephritis. Fosfomycin is a second-line drug and can be useful in patients with drug allergies.
1. When a patient is on aminoglycoside therapy, the nurse will monitor the patient for which indicators of potential toxicity?
a.
Fever
b.
White blood cell count of 8000 cells/mm3
c.
Tinnitus and dizziness
d.
Decreased blood urea nitrogen (BUN) levels
ANS: C
Dizziness, tinnitus, hearing loss, or a sense of fullness in the ears could indicate ototoxicity, a potentially serious toxicity in a patient. Nephrotoxicity is indicated by rising blood urea nitrogen and creatinine levels. Fever may be indicative of the patient's infection; a white blood cell count of 7000 cells/mm3 is within the normal range of 5000 to 10,000 cells/mm3.
3. Which nursing diagnosis is appropriate for a patient who has started aminoglycoside therapy?
a.
Constipation
b.
Risk for injury (renal damage)
c.
Disturbed body image related to gynecomastia
d.
Imbalanced nutrition, less than body requirements, related to nausea
ANS: B
Patients on aminoglycoside therapy have an increased risk for injury caused by nephrotoxicity. The other options are incorrect.
5. A patient is receiving aminoglycoside therapy and will be receiving a beta-lactam antibiotic as well. The patient asks why two antibiotics have been ordered. What is the nurse's best response?
a.
"The combined effect of both antibiotics is greater than each of them alone."
b.
"One antibiotic is not strong enough to fight the infection."
c.
"We have not yet isolated the bacteria, so the two antibiotics are given to cover a wide range of microorganisms."
d.
"We can give a reduced amount of each one if we give them together."
ANS: A
Aminoglycosides are often used in combination with other antibiotics, such as beta-lactams or vancomycin, in the treatment of various infections because the combined effect of the two antibiotics is greater than that of either drug alone.
9. A 79-year-old patient is receiving a quinolone as treatment for a complicated incision infection. The nurse will monitor for which adverse effect that is associated with these drugs?
a.
Neuralgia
b.
Double vision
c.
Hypotension
d.
Tendonitis and tendon rupture
ANS: D
A black-box warning is required by the U.S. Food and Drug Administration for all quinolones because of the increased risk for tendonitis and tendon rupture with use of the drugs. This effect is more common in elderly patients, patients with renal failure, and those receiving concurrent glucocorticoid therapy (e.g., prednisone). The other options are not common adverse effects.
A nurse is administering a daily dose of tobramycin at 1000. At which time should the nurse obtain the patient's blood sample to determine the trough level?
1. 8:00 AM
2. 9:00 AM
3. 11:30 AM
4. 12:00 PM
2
A patient who is receiving an aminoglycoside (gentamicin) has a urinalysis result with all of these findings. Which finding should a nurse associate most clearly with an adverse effect of gentamicin?
1.White blood cells (WBCs)
2.Glucose
3.Ketones
4.Protein
4.
A patient is receiving an aminoglycoside (tobramycin) antibiotic. A nurse asks the patient to choose daily meal selections, to which the patient responds, "Oh, dear, I don't want another IV." The nurse makes which assessment about the patient's response?
1.Some hearing loss may have occurred.
2.The confusion is due to the hospital stay.
3.A nutrition consult most likely is needed.
4.The patient has a family history of dementia.
1.
A nurse monitors a patient who is receiving an aminoglycoside (gentamicin) for symptoms of vestibular damage. Which finding should the nurse expect the patient to have first?
1.Unsteadiness
2.Vertigo
3.Headache
4.Dizziness
3.
The nurse knows that there is an increased risk of ototoxicity in a patient receiving an aminoglycoside if which level is high?
1.Concentration
2.Trough
3. Peak
4.Dose
2.
When administering an aminoglycoside to a patient with myasthenia gravis, it is most important for the nurse to assess what?
1.Deep tendon reflexes
2.Breath sounds
3. Eyelid movement
4. Muscle strength
2.
A patient who is receiving an aminoglycoside develops flaccid paralysis and impaired breathing. Which medication does the nurse anticipate administering?
1.Magnesium sulfate [Epsom salt]
2.Potassium chloride [K-Dur]
3.Sodium bicarbonate [Citrocarbonate]
4.Calcium gluconate [Kalcinate]
4.
Which enteral aminoglycoside would the nurse expect to be ordered preoperatively for a patient having intestinal surgery?
1.Gentamicin
2.Tobramycin
3.Amikacin
4.Neomycin
4.
Before administering an aminoglycoside, it is most important for the nurse to assess the patient for a history of what?
1.Myasthenia gravis
2.Asthma
3.Hypertension
4.Diabetes mellitus
1.
Which statements about ototoxicity and aminoglycosides does the nurse identify as true? (Select all that apply.)
1.The risk of ototoxicity is related primarily to excessive peak levels.
2.The first sign of impending cochlear damage is headache.
3.The first sign of impending vestibular damage is headache.
4. Ototoxicity is largely irreversible.
5. Use of aminoglycosides for less than 10 days is recommended to avoid ototoxicity
3.4.5.
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