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 D
Explanation
Furosemide is a loop diuretic that blocks water reabsorption in the loop of Henle promoting diuresis. It also causes potassium loss in urine leading to hypokalemia. Checking potassium levels before administration of furosemide prevents worsening already existing hypokalemia.
Hypokalemia causes complications like cardiac dysrhythmias, muscle weakness, and fatigue. The nurse should monitor the client for signs and symptoms of hypokalemia and notify the provider appropriately
A. furosemide does not affect the blood glucose levels
B. furosemide is used to lower blood pressure by reducing venous return.
C. furosemide reduces fluid load by blocking water reabsorption in the kidney
Correct Answer is D
Explanation
Iron absorption is enhanced when taken between meals as some foods may inhibit absorption especially if the food contains tannins, calcium and fiber. Taking ferrous sulfate tablets between meals helps maximize iron absorption and ensures optimal effectiveness in treating iron deficiency anemia.
A. Taking ferrous sulfate between meals does not prevent constipation.
B. Taking iron supplements with food may help reduce gastrointestinal side effects such as nausea and irritation.
C. Ferrous sulfate can cause nausea regardless of time taken
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