A client who is receiving intravenous vancomycin reports feeling dizzy and flushed. The nurse observes that the client has a macular rash on the face and neck. Which of the following actions should the nurse take first?

Stop the infusion and notify the provider.

Administer diphenhydramine as prescribed.

Monitor the client's vital signs and oxygen saturation.

Slow down the infusion rate and observe for improvement.

Answer and Explanation

The Correct Answer is A

A) This is correct because stopping the infusion and notifying the provider are the priority actions for a client who is experiencing signs and symptoms of anaphylaxis, which is a life-threatening allergic reaction to a medication. The nurse should also prepare to administer epinephrine as prescribed.

B) This is incorrect because administering diphenhydramine as prescribed is not the first action for a client who is experiencing anaphylaxis. Diphenhydramine is an antihistamine that can help relieve some symptoms of an allergic reaction, but it is not effective for reversing bronchoconstriction or hypotension that may occur in anaphylaxis.

C) This is incorrect because monitoring the client's vital signs and oxygen saturation is not the first action for a client who is experiencing anaphylaxis. Although these are important assessments, they are not as urgent as stopping the infusion and notifying the provider.

D) This is incorrect because slowing down the infusion rate and observing for improvement are not appropriate actions for a client who is experiencing anaphylaxis. Slowing down or continuing the infusion may worsen the client's condition and delay treatment.

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Correct Answer is C

Explanation

Rapid heart rate and palpitations are potential signs of a medication error, particularly if the client is receiving medication that can affect cardiac function. These symptoms can indicate an adverse reaction or an overdose of certain medications, such as those that affect the cardiovascular system. Monitoring the client's cardiac status is crucial in detecting and managing potential medication errors.

Incorrect choices:

a) Mild headache and dizziness: While these symptoms may be bothersome, they are generally not indicative of a medication error unless they persist or worsen.

b) Temporary nausea and vomiting: Nausea and vomiting can occur as side effects of medications, and they may not necessarily indicate a medication error.

d) Transient muscle weakness and fatigue: Although muscle weakness and fatigue can be associated with medication errors, they are less specific and may be caused by various other factors. Rapid heart rate and palpitations are more concerning in this context.

A. Use two client identifiers before administering any medication. B. Check the expiration date of the medication before administering it. C. Compare the medication label with the prescription three times. D. Administer the medication as soon as possible after receiving it from the pharmacy. E. Document the medication administration after completing other tasks.

Correct Answer is ["A","B","C"]

Explanation

A) This is correct because using two client identifiers, such as name and date of birth, is a standard safety measure to ensure that the right medication is given to the right client.

B) This is correct because checking the expiration date of the medication before administering it is another safety measure to prevent giving expired or ineffective medications to clients.

C) This is correct because comparing the medication label with the prescription three times (before, during, and after preparing the medication) is a recommended practice to prevent errors such as wrong dose, wrong route, or wrong time.

D) This is incorrect because administering the medication as soon as possible after receiving it from the pharmacy may increase the risk of errors due to haste or distraction. The nurse should follow the prescribed schedule and administer the medication within a reasonable time frame.

E) This is incorrect because documenting the medication administration after completing other tasks may lead to forgetting or omitting important information. The nurse should document the medication administration as soon as possible after giving it to the client.

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A client who is receiving intravenous vancomycin reports feeling dizzy and flushed. The nurse observes that the client has a macular rash on the face and neck. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client for signs and symptoms of a medication error. Which of the following manifestations should the nurse be most concerned about?

Correct Answer is C

Explanation

A nurse is reviewing the medication administration record of a client who has a history of medication errors. Which of the following actions should the nurse take to prevent medication errors? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

A nurse suspects a medication error in a client who recently started a new medication. Which of the following assessments would support this suspicion?

A client who is receiving intravenous vancomycin reports feeling dizzy and flushed. The nurse observes that the client has a macular rash on the face and neck. Which of the following actions should the nurse take first?

A nurse is preparing to administer insulin to a client who has diabetes mellitus. The nurse notices that the insulin vial has a small amount of white precipitate at the bottom. Which of the following actions should the nurse take?

A nurse is teaching a client who is prescribed warfarin about the signs and symptoms of bleeding that should be reported to the provider. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)