# A 68-year-old septic ICU client receives IV tobramycin, IV vancomycin, IV furosemide drip, and recent IV contrast for CT. On day 4, creatinine has risen from 1.1 to 2.0 mg/dL and urine output has dropped to 0.3 mL/kg/h. The pharmacy reports a tobramycin trough of 3.8 mg/L. Which combined nursing and care-coordination action is most appropriate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375228&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

A 68-year-old septic ICU client receives IV tobramycin, IV vancomycin, IV furosemide drip, and recent IV contrast for CT. On day 4, creatinine has risen from 1.1 to 2.0 mg/dL and urine output has dropped to 0.3 mL/kg/h. The pharmacy reports a tobramycin trough of 3.8 mg/L. Which combined nursing and care-coordination action is most appropriate?

## Option

1. Notify the prescriber of the elevated tobramycin trough and recommend an additional one-time dose to ensure adequate peak levels, then resume the regular dosing schedule; increase the IV fluid rate to 200 mL/h to enhance renal clearance of the drug; administer oral N-acetylcysteine 600 mg twice daily as a nephroprotective agent; continue the vancomycin and furosemide drip at current rates; arrange for a repeat tobramycin level before the third subsequent dose.
2. Continue the current tobramycin and vancomycin regimens as prescribed, because sepsis requires uninterrupted antimicrobial therapy; increase IV fluids to 250 mL/h to address prerenal AKI; continue the furosemide drip to maintain urine flow and prevent fluid overload; send blood cultures and a procalcitonin level to guide antibiotic adjustments; monitor creatinine and urine output every 6 hours.
3. Hold the next tobramycin dose and contact the prescriber and pharmacist; review and minimize concurrent nephrotoxins (consider holding furosemide drip, deferring further contrast, reassessing vancomycin dose); anticipate dose hold or discontinuation and culture-guided change to a non-aminoglycoside agent; monitor strict I/O, daily weight, electrolytes, and ototoxicity surveillance; ensure adequate volume status without precipitating fluid overload. **✔ Correct answer**
4. Administer ketorolac 15 mg IV every 6 hours to reduce renal parenchymal inflammation; hold the next dose of vancomycin to avoid further gastrointestinal irritation; continue the tobramycin and furosemide drip as prescribed; initiate strict bed rest to decrease metabolic demand; monitor daily weights, serum creatinine, and BUN; encourage oral fluid intake of at least 2 L per day unless contraindicated; record strict intake and output every shift.

**Correct answer: 3**

## Explanation

Aminoglycoside nephrotoxicity is markedly amplified by concurrent nephrotoxins, including loop diuretics (potassium and magnesium losses also potentiate ototoxicity), IV iodinated contrast (vasoconstriction and tubular injury), vancomycin (additive proximal tubule toxicity), NSAIDs, ACE inhibitors, and ARBs. The supratherapeutic trough (3.8 mg/L; goal less than 2 mg/L), the rising creatinine, and oliguria all confirm AKI from polypharmacy and possibly underlying sepsis. Standard nursing/care-coordination response: (1) hold the next tobramycin dose and notify prescriber and pharmacist immediately; (2) coordinated review of all nephrotoxins — hold or substitute the furosemide drip if possible (or address the volume status with thiazide combination/ultrafiltration), defer additional contrast, recalculate vancomycin dosing or change agents, review ACEi/ARBs, NSAIDs; (3) anticipate aminoglycoside hold or discontinuation, change to a non-aminoglycoside agent guided by culture; (4) strict intake and output, daily weight, electrolytes (K, Mg), and creatinine trend; (5) ototoxicity surveillance — hearing changes, tinnitus, vertigo, gait; (6) volume optimization — sufficient perfusion to avoid prerenal worsening but avoid overload; (7) consider nephrology and audiology consults; (8) fall precautions if vestibular involvement. Continuing all, increasing dose, and adding NSAID are all unsafe.

## In-depth explanation

Polypharmacy nephrotoxicity in a septic patient. Hold tobramycin, coordinate stripping nephrotoxins, change to a non-aminoglycoside agent, monitor strict I/O and ototoxicity. NSAIDs and dose escalation are traps.

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