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
Sucralfate is a medication used to treat gastric and duodenal ulcers by forming a protective coating over the ulcer site to prevent acid exposure. Taking it 1 hour before meals and bedtime ensures formation of a coat prior to production of acid during digestion or lying down.
A. Taking sucralfate "as needed" may lead to overdose as well as reduced effectiveness
B. There's no need to reduce fluid intake with sucralfate.
C. Sucralfate should not be taken with antacids, as they can interfere with its effectiveness by altering its pH-dependent mechanism of action. It's generally recommended to take sucralfate at least 30 minutes before or after taking antacids.
Correct Answer is C
Explanation
In liver cirrhosis, the impaired liver function leads to increased levels of ammonia in the blood. Such high levels can lead to hepatic encephalopathy. Use of lactulose promotes excretion of ammonia through acidification of ammonia to ammonium ions which are not readily absorbed into the blood stream.
A, B, D- Lactulose does not affect potassium, glucose and bicarbonate levels in the bloodstream.
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