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

- Administration of subcutaneous heparin follows the following steps

Wipe the chosen area with alcohol and avoid rubbing
Remove the cap from needle
Gently pinch a fold of skin
Insert the needle at 45 to 90 degrees
Push down the drug into the tissue
Draw the needle out slowly at the same angle
Apply a cotton ball light for 1-2 minutes
Monitor for bleeding

A. On the nonoperative side B. Sims. C. Semi-Fowler's D. Prone

Correct Answer is A

Explanation

After a pneumonectomy, positioning the client on the nonoperative side helps maximize ventilation to the remaining lung and facilitates drainage of secretions. Placing the client on the nonoperative side allows for better perfusion and ventilation of the remaining lung, which can improve oxygenation and respiratory function.

B-sims position is used during insertion of suppository of a rectal exam

C -Semi-Fowler's position is used in clients with heart failure and pulmonary edema to promoted ventilation in the upper lungs

D-Prone position is used during surgical procedures involving the back in the operating room

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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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