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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Related Questions
Correct Answer is C
Explanation
Zidovudine (AZT) is an antiretroviral drug used in treatment of HIV to suppress viral replication. It causes aplastic anemia, suppression of the bone marrow, leasing to reduces production of all hematopoietic cell lines including red blood cells, white blood cells, and platelets.
A, B, and D - are not associated with Zidovudine use
Correct Answer is A
Explanation
Phenytoin is a lifelong medication for clients presenting with unprovoked seizures. The statement shows that the client has not understood their current management plan or is in denial and requires further counselling to promote adherence.
B.Notifying the doctor before taking any other medication is important as certain drug interactions can lead to toxicity of inadequate blood levels of phenytoin.
C.This is correct as it shows understanding that phenytoin can cause oral adverse effects such as gingival hyperplasia
D.Shows understanding that some drug preparations could have incipient that may cause adverse effects that the originally tolerated agent
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