A nurse is assessing a client who is receiving vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?

Decrease the infusion rate on the IV.

Document that the client experienced an anaphylactic reaction to the medication.

Change the IV infusion site.

Apply cold compresses to the neck area.

Answer and Explanation

The Correct Answer is A

Choice A reason: Decrease the Infusion Rate on the IV

Decreasing the infusion rate on the IV is the appropriate action to take when a client experiences flushing of the neck and tachycardia while receiving vancomycin. These symptoms are indicative of vancomycin flushing syndrome (VFS), also known as “red man syndrome,” which is a reaction caused by the rapid infusion of vancomycin. Slowing the infusion rate allows the body more time to metabolize the drug and can help alleviate the symptoms.

Choice B reason: Document that the Client Experienced an Anaphylactic Reaction to the Medication

Documenting that the client experienced an anaphylactic reaction is not accurate in this scenario. Vancomycin flushing syndrome is an anaphylactoid reaction, not an anaphylactic one. Anaphylactoid reactions are not mediated by IgE antibodies and do not require prior sensitization to the drug. Therefore, it is important to distinguish between the two and document the reaction correctly.

Choice C reason: Change the IV Infusion Site

Changing the IV infusion site is not necessary in this case. The symptoms of flushing and tachycardia are related to the rate of vancomycin infusion, not the site of infusion. Therefore, changing the site would not address the underlying issue.

Choice D reason: Apply Cold Compresses to the Neck Area

Applying cold compresses to the neck area may provide some symptomatic relief, but it does not address the root cause of the reaction. The primary intervention should be to slow the infusion rate to prevent further release of histamine and alleviate the symptoms.

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Correct Answer is B

Explanation

Choice A reason: Smallpox

Smallpox is a viral disease caused by the variola virus. It was eradicated globally in 1980 through a successful vaccination campaign. Treatment for smallpox primarily involves supportive care and antiviral medications, such as tecovirimat, rather than antibiotics like ciprofloxacin. Ciprofloxacin is ineffective against viral infections, including smallpox.

Choice B reason: Anthrax

Anthrax is a serious infectious disease caused by the bacterium Bacillus anthracis. Ciprofloxacin is one of the primary antibiotics used for the treatment and post-exposure prophylaxis of anthrax. It works by inhibiting bacterial DNA gyrase, which is essential for bacterial replication. Ciprofloxacin is effective against both cutaneous and inhalational forms of anthrax, making it a critical component in the management of anthrax exposure.

Choice C reason: Ebola virus

Ebola virus disease (EVD) is caused by the Ebola virus, a member of the Filoviridae family. Treatment for EVD primarily involves supportive care, including rehydration and management of symptoms. Antiviral medications, such as remdesivir, may also be used. Ciprofloxacin, being an antibiotic, is not effective against viral infections like Ebola.

Choice D reason: Sarin gas

Sarin gas is a highly toxic nerve agent used in chemical warfare. Exposure to sarin gas requires immediate medical intervention, including the administration of antidotes such as atropine and pralidoxime, as well as supportive care. Antibiotics like ciprofloxacin are not used in the treatment of chemical agent exposure, as they do not counteract the effects of nerve agents.

A. The medication will reduce inflammation. B. The medication will decrease coughing episodes. C. The medication will prevent wheezing. D. The medication will open the airway. E. The medication will stimulate the flow of mucus.

Correct Answer is ["C","D"]

Explanation

Choice A reason:

Albuterol is primarily a bronchodilator and does not significantly reduce inflammation. Anti-inflammatory medications, such as corticosteroids, are typically used to address inflammation in the airways.

Choice B reason:

While albuterol can help reduce coughing episodes by opening the airways and making breathing easier, it is not its primary function. Coughing can be a symptom of bronchospasm, which albuterol helps to relieve.

Choice C reason:

Albuterol is effective in preventing wheezing by relaxing the muscles around the airways, which helps to open them up and allow more air to flow through. This action helps to alleviate wheezing, a common symptom of asthma and other respiratory conditions.

Choice D reason:

The primary function of albuterol is to open the airways. It is a bronchodilator that works by relaxing the smooth muscles around the airways, allowing them to widen and making it easier to breathe.

Choice E reason:

Albuterol does not stimulate the flow of mucus. Its main action is to relax the airway muscles and improve airflow. Mucus production is typically managed by other medications or treatments.

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A nurse is assessing a client who is receiving vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (Select all that apply)

Correct Answer is ["C","D"]

Explanation

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