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 C

Explanation

Methotrexate causes hyperuricemia which may predispose to kidney stones. Adequate hydration help flush out the uric acid preventing stone formation
A-Although methotrexate can cause nausea and vomiting, this does not always happen, therefore, no need for the antiemetic before intake
B-Taking methotrexate with an NSAID increases risk of gastrointestinal irritation
D-Methotrexate cause stomatitis which may be aggravated by use of alcohol-based mouth wash

A. Increase caffeine intake. B. Reduce calorie intake. C. Take this medication before bedtime. D. Avoid activities that require alertness such as driving.

Correct Answer is D

Explanation

Methylphenidate is a CNS agent used in the management of ADHD. It has the potential to cause dizziness or drowsiness and clients should be advised to avoid driving or operation of any machinery as it may lead to accidents.

A- Methylphenidate is a CNS agent used in the management of ADHD. It has nopotential interaction with caffeine.

B- Methylphenidate caused significant decrease in appetite with subsequent weight loss. The parents should be advised to increase the client’s caloric intake to promote healthy weight gain.

C- Methylphenidate causes insomnia and taking the medication right before bedtime leads to poor sleep pattern.

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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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