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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Fat overload syndrome is a rare but serious complication that can occur in clients receiving lipid infusion. It is typically characterized by fever.
Although spontaneous hemorrhage can occur, peripheral edema is not a typical feature of fat overload syndrome.
Hypertension is not a typical feature of fat overload syndrome. However, hypotension may occur due to fluid shift and vasodilation.
Erythema can occur at the site of infusion during lipid infusion. However, it is not a typical feature of fat overload syndrome.
Correct Answer is D
Explanation
Rationale- Levothyroxine is a synthetic form of thyroxine that is used in the management of symptomatic hypothyroidism. It is used to provide the body with thyroxine to sustain basal metabolism in cases of hypothyroidism.
A-Levofloxacin is a fluoroquinolone antibiotic for treatment of infections
B- Ionizing radiation used in the destroying active thyroid tissue in the cases of hyperthyroidism
C- Sumatriptan is serotonin antagonist used in the treatment of migraines
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