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: Bleeding gums is a possible adverse effect of taking gingko biloba, as it may increase the risk of bleeding by inhibiting platelet aggregation and interfering with clotting factors. Gingko biloba may also interact with other medications that affect bleeding, such as anticoagulants, antiplatelets, or NSAIDs. The nurse should advise the client to monitor for signs of bleeding, such as bruising, nosebleeds, or hematuria, and report them to the provider.
Choice B reason: Decreased alertness is not a likely adverse effect of taking gingko biloba, as it may have the opposite effect of enhancing cognitive function and memory. Gingko biloba may improve blood flow to the brain and protect against oxidative stress and neuronal damage. The nurse should inform the client that gingko biloba may take several weeks to show its benefits and that the evidence for its effectiveness is inconclusive.
Choice C reason: Breast enlargement is not a known adverse effect of taking gingko biloba, as it does not affect the hormonal levels or the breast tissue. Gingko biloba may have some estrogenic activity, but it is not significant enough to cause gynecomastia or breast tenderness. The nurse should assess the client for other possible causes of breast enlargement, such as medications, liver disease, or tumors.
Choice D reason: Bad breath is not a common adverse effect of taking gingko biloba, as it does not affect the oral hygiene or the digestive system. Gingko biloba may have a mild odor, but it is not unpleasant or persistent. The nurse should advise the client to maintain good oral care and to check for other possible causes of bad breath, such as infections, dental problems, or dietary factors.
Correct Answer is C
Explanation
Choice A reason: Taking this medication with food is not necessary, as lisinopril can be taken with or without food. Food does not affect the absorption or effectiveness of lisinopril.
Choice B reason: Facial swelling is not an expected effect of this medication, but a serious adverse reaction that indicates angioedema. Angioedema is a life-threatening condition that causes swelling of the face, tongue, throat, and airway. It requires immediate medical attention and discontinuation of lisinopril.
Choice C reason: Reporting a cough to the provider is an important instruction, as a cough is a common and annoying side effect of lisinopril. Lisinopril belongs to the class of angiotensin-converting enzyme (ACE) inhibitors, which can cause a dry, persistent, nonproductive cough. The cough may interfere with the client's quality of life and adherence to the medication. The provider may prescribe an alternative medication, such as an angiotensin II receptor blocker (ARB), to avoid the cough.
Choice D reason: Increasing the intake of potassium-rich foods is not advisable, as lisinopril can cause hyperkalemia (high potassium levels) due to decreased potassium excretion in the urine. Clients should monitor their potassium levels and avoid excessive intake of potassium supplements or foods, such as bananas, oranges, potatoes, and tomatoes.
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