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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Correct Answer is B
Explanation
Theophylline has a narrow therapeutic window which increase the risk of overdose and toxicity. It is also given at very small doses which could be difficult for the nursing staff to accurately titrate the drops and hence requires an infusion pump
A. Infusion of theophylline loading dose should not exceed 25mg/min due to risk of seizures and cardiac arrhythmias
C. Use of a test dose is not necessary as the risk of hypersensitivity with theophylline is very low.
D. Covering the IV container with dark paper is not necessary for the administration of theophylline.
Correct Answer is B
Explanation
B. Taking sucralfate before meals allows it to form a protective coating on the ulcer, which can help to reduce irritation and promote healing.
A. Storing sucralfate in the refrigerator is unnecessary. Sucralfate tablets should be stored at room temperature away from moisture and heat.
C. It can be dissolved or broken
D. Antacids can interfere with the effectiveness of sucralfate by altering its pH-dependent mechanism of action. Therefore, they should be taken at least 30 minutes before or after sucralfate.
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