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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Diluting phenytoin with sterile water before injecting is not recommended, as phenytoin is incompatible with most used diluents. Diluting it can lead to precipitation and potentially cause adverse effects such as tissue irritation and phlebitis.
B. Administering the medication over 1 min is recommended. Phenytoin should be administered at a rate of 50mg/min.
C. Following the IV injection with sterile water is unnecessary and not indicated for administering phenytoin.
D.Phenytoin precipitates out of solution when mixed with certain diluents or when administered too quickly. Crystallized phenytoin can cause local irritation, tissue damage, and potentially more serious adverse effects. Therefore, it should not be administered at all.

A. milk B. Cheddar cheese C. Cooked carrots D. Bananas

Correct Answer is D

Explanation

Furosemide is a loop diuretic that increases the excretion of potassium in the urine, leading to hypokalemia. Therefore, supplementation is important for clients on furosemide to prevent complications related to hypokalemia. One medium-sized banana contains approximately 400-450 mg of potassium and hence can help replenish potassium levels in individuals taking furosemide.
A, B, C contain very low potassium levels as compared to bananas

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is preparing to administer phenytoin 50 mg IV bolus to a client Who has a seizure disorder. The medication is supplied as a 50 mg/mL vial. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium?

Correct Answer is D

Explanation

A nurse is caring for a client Who has diabetes insipidus and is receiving vasopressin. The nurse should identify Which of the following findings as an indication that the medication is effective?

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation?

A nurse is providing teaching to a client who has breast cancer about the adverse effects of chemotherapy. Which of the following client statements indicates an understanding of the teaching?

A nurse is teaching a client who has diabetes mellitus and receives 25 units of NPH insulin every morning if her blood glucose level is above 200 mg/dL. Which of the following information should the nurse include?

A nurse is caring for a client who has heart failure and a new prescription for furosemide. For which of the following adverse effects should the nurse monitor?

A nurse is planning to administer butorphanol to a client Who is in labor. Which of the following medications should the nurse plan to have available to reverse the action of this medication?

A nurse is teaching a client about the adverse effects of cisplatin. Which of the following adverse effects should the nurse include in the teaching?