A nurse is assessing a client after administering IV vancomycin. Which of the following findings is the nurse's priority to report to the provider?
Client report of a headache
Audible inspiratory stridor
Client report of tinnitus
Localized redness at the catheter insertion site
The Correct Answer is B
Choice A reason: Client report of a headache is not the nurse's priority to report to the provider. A headache is a common and mild side effect of vancomycin, which is an antibiotic used to treat serious infections. A headache may be caused by dehydration, stress, or other factors, and can be relieved by drinking fluids, resting, or taking analgesics.
Choice B reason: Audible inspiratory stridor is the nurse's priority to report to the provider. Stridor is a high-pitched, wheezing sound that occurs when breathing in, and indicates a narrowing or obstruction of the airway. Stridor may be a sign of a severe allergic reaction, or anaphylaxis, to vancomycin, which can be life-threatening. Anaphylaxis can also cause swelling of the face, lips, tongue, or throat, difficulty breathing, low blood pressure, and shock. The nurse should stop the infusion, administer epinephrine, and monitor the client's vital signs.
Choice C reason: Client report of tinnitus is not the nurse's priority to report to the provider. Tinnitus is a ringing or buzzing sound in the ears, and may be a rare and serious side effect of vancomycin. Tinnitus may indicate damage to the inner ear, or ototoxicity, which can lead to hearing loss. The nurse should check the client's hearing and report any changes to the provider. The provider may adjust the dose or frequency of vancomycin, or switch to another antibiotic.
Choice D reason: Localized redness at the catheter insertion site is not the nurse's priority to report to the provider. Redness at the catheter insertion site may indicate irritation, inflammation, or infection of the skin or vein, and may be caused by the needle, the catheter, or the medication. The nurse should inspect the site, clean it with antiseptic, and apply a sterile dressing. The nurse should also monitor the site for signs of phlebitis, such as pain, swelling, warmth, or pus. The nurse may need to change the catheter or the infusion site if the redness persists or worsens.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Infection is the correct condition that the client is at increased risk for. Agranulocytosis is a severe decrease in the number of granulocytes, which are a type of white blood cell that fight infection. Propylthiouracil is an antithyroid drug that can cause agranulocytosis as a rare but serious side effect. The client with agranulocytosis is more susceptible to bacterial and fungal infections, and may present with fever, sore throat, mouth ulcers, and skin lesions.
Choice B reason: Excessive bleeding is not the correct condition that the client is at increased risk for. Agranulocytosis does not affect the platelets, which are the blood cells that help with clotting. Propylthiouracil does not cause bleeding disorders, although it may interact with anticoagulants and increase their effect.
Choice C reason: Hyperglycemia is not the correct condition that the client is at increased risk for. Agranulocytosis does not affect the insulin, which is the hormone that regulates blood glucose levels. Propylthiouracil does not cause hyperglycemia, although it may interfere with the metabolism of oral hypoglycemic agents and decrease their effect.
Choice D reason: Ecchymosis is not the correct condition that the client is at increased risk for. Ecchymosis is a bruise caused by bleeding under the skin. Agranulocytosis does not cause ecchymosis, as it does not affect the blood vessels or the platelets. Propylthiouracil does not cause ecchymosis, although it may increase the risk of skin rash and pruritus.
Correct Answer is A
Explanation
Choice A reason: Grapefruit juice should be avoided while taking verapamil, as it can increase the blood levels of the medication and cause adverse effects such as hypotension, bradycardia, and dizziness. Grapefruit juice inhibits the enzyme that metabolizes verapamil in the liver, leading to higher concentrations of the drug in the bloodstream.
Choice B reason: Orange juice is not a contraindication for verapamil, as it does not affect the metabolism or absorption of the medication. Orange juice is a good source of vitamin C and potassium, which may benefit clients with hypertension.
Choice C reason: Milk is not a contraindication for verapamil, as it does not affect the metabolism or absorption of the medication. Milk is a good source of calcium and protein, which may benefit clients with hypertension.
Choice D reason: Coffee is not a contraindication for verapamil, as it does not affect the metabolism or absorption of the medication. However, coffee contains caffeine, which is a stimulant that can increase the heart rate and blood pressure. Therefore, clients with hypertension should limit their intake of caffeine and other stimulants.
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