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
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Correct Answer is C
Explanation
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A, B, D- features of hypothyroidism
Correct Answer is A
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Lactulose is used to treat hepatic encephalopathy in clients with cirrhosis. It works by promoting the excretion of ammonia in the stool, thus reducing its absorption in the intestines and helping to manage hepatic encephalopathy. However, if lactulose is administered too quickly or in excessive amounts, it can cause gastrointestinal side effects such as vomiting.
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