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.

Answer and Explanation

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 A

Explanation

Crushing or breaking naproxen tablets can alter their pharmacokinetics and pharmacodynamics leading to an increased risk of gastrointestinal side effects or reduced

effectiveness of the medication. The tablet should therefore be taken whole.

A. Dilute the medication with dextrose 5k in water. B. Administer a saline solution after injection. C. Administer the medication at 100 mg/min. D. Hold the injection if seizure activity is present.

Correct Answer is B

Explanation

It is recommended that every injection of phenytoin be followed by infusion of at least 50 to 100mls of normal saline infusion. This is important to prevent local irritation that occurs as surrounding tissues react to the medication.

A. Mixing phenytoin in dextrose 5% is not recommended due risk of precipitation of the Phenytoin acid

C. Phenytoin should be given at a date of 50mg/min or less to reduce the risk of toxicity

D. The injection should not be held as it is used to manage the seizure unless it is not safe for the nurse to give it

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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