A nurse is assessing a client who is receiving IV vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?
Document that the client experienced an anaphylactic reaction to the medication.
Decrease the infusion rate on the IV.
Apply cold compresses to the neck area.
Change the IV infusion site.
The Correct Answer is B
A. The symptoms described (flushing and tachycardia) are not indicative of an anaphylactic reaction, which typically includes symptoms like difficulty breathing, hives, or swelling. Documenting it as an anaphylactic reaction would be misleading and could lead to inappropriate management.
B. Slowing the infusion rate can help mitigate the symptoms of Red Man Syndrome, which is often related to the rate of vancomycin administration. The recommended infusion rate for vancomycin is generally over at least 60 minutes, and reducing the rate can help alleviate symptoms.
C. Applying cold compresses should help with pain but as important like documentation.
D. The infusion should be continued and not used again for the client.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale- Sucralfate is used for coating the lining of gastric ulcers to prevent exposure to acid allowing for healing. It binds to protein containing exudate to form a paste-like substance that coats the ulcers.
B-Sucralfate has no effect of quality of vision
C-Sucralfate has no role in prophylaxis in infections
D-Sucralfate relieves pain in H. Pylori induced gastric ulcers but no effect of infection control
Correct Answer is C
Explanation
Allopurinol is used to lower uric acid levels in the body in gouty arthritis preventing acute attacks. Increasing fluid intake while taking allopurinol is important because it helps to prevent the formation of kidney stones by flushing out uric acid, a potential side effect of the medication
A. Taking an antihistamine for a rash caused by allopurinol is not recommended without consultation
B. Taking aspirin for a fever while on allopurinol is not recommended without consultation with a physician
D. Allopurinol can be taken with or without food.
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