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","B","D"]
Explanation
Choice A reason: Removing the patch for 10 to 12 hours daily is a correct instruction. This allows the client to have a nitrate-free period, which prevents the development of tolerance to the medication. Tolerance reduces the effectiveness of nitroglycerin in relieving anginal pain. The client should remove the patch at night, when the risk of angina is lower, and apply a new patch in the morning.
Choice B reason: Applying the patch to a hairless area and rotating sites is a correct instruction. This prevents skin irritation and enhances absorption of the medication. The client should avoid applying the patch to areas that are exposed to heat, sunlight, or friction, as these factors can increase the release of nitroglycerin and cause hypotension.
Choice C reason: Applying a new patch at the onset of anginal pain is not a correct instruction. Transdermal nitroglycerin is used for the prevention, not the treatment, of anginal attacks. The onset of action of transdermal nitroglycerin is slow, and it may take several hours to reach peak effect. The client should use sublingual nitroglycerin, which has a rapid onset of action, to treat acute anginal pain.
Choice D reason: Applying a new patch each morning is a correct instruction. This ensures that the client has a steady and adequate supply of nitroglycerin throughout the day, when the risk of angina is higher. The client should apply the patch to a different site each day, and remove the old patch before applying the new one.
Choice E reason: Applying the patch to dry skin and covering the area with plastic wrap is not a correct instruction. This can cause skin maceration, which is the softening and breaking down of the skin due to moisture. This can increase the risk of infection and reduce the absorption of the medication. The client should apply the patch to clean and dry skin, and avoid covering the area with any dressing or tape.
Correct Answer is D
Explanation
Choice A reason: The extra letters after the name of the medication do not mean it is a stronger dose, but that it is a combination of two different medications. Metoprolol is a beta-blocker that lowers blood pressure and heart rate, while hydrochlorothiazide is a diuretic that reduces fluid retention and blood volume. The combination of these two medications may have a synergistic effect and lower blood pressure more effectively than either one alone.
Choice B reason: The client will have to do some things differently because it is not the same medication, but a combination of two medications. The client will have to monitor their blood pressure, weight, fluid intake, and electrolyte levels more closely, as the addition of hydrochlorothiazide may increase the risk of dehydration, hypotension, and hypokalemia. The client will also have to avoid alcohol, salt, and potassium supplements, as they may interact with the medication and affect its efficacy or safety.
Choice C reason: The client will still have to diet to lose weight, as the medication does not cause weight loss, but may cause weight gain due to fluid retention. The client will have to follow a healthy diet that is low in sodium, fat, and cholesterol, as these may worsen hypertension and increase the risk of cardiovascular complications. The client will also have to exercise regularly, as this may help lower blood pressure and improve overall health.
Choice D reason: The client may experience fewer side effects with the new medication, as the combination of metoprolol and hydrochlorothiazide may lower the dose and frequency of each medication, and reduce the adverse effects of each one. For example, metoprolol may cause fatigue, dizziness, or bradycardia, while hydrochlorothiazide may cause dry mouth, headache, or gout. The combination of these two medications may balance out these effects and improve the client's tolerance and compliance.
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