A nurse is caring for a client on a medical-surgical unit. Complete the following sentence by using the lists of options.
The nurse should first
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Rationale for Correct Choices:
- Stop the IV infusion: The client is showing signs of a severe allergic reaction, including flushing, generalized itching, hypotension, tachycardia, hypoxia, and difficulty breathing shortly after vancomycin administration. Immediate cessation of the infusion is critical to prevent progression of anaphylaxis.
- Anaphylaxis: The client is exhibiting the classic signs of an anaphylactic-type reaction. The rapid infusion rate (325 mL/hr) is very high for Vancomycin and often causes Red Man Syndrome, which is a histamine release reaction. However, the presence of difficulty breathing elevates this to anaphylactic or severe hypersensitivity reaction, requiring the most urgent response.
Rationale for Incorrect Choices:
- Administer epinephrine: Epinephrine is the first-line treatment for anaphylaxis, but it is administered after stopping the offending agent. Halting the infusion is the initial, priority nursing action.
- Request a serum peak drug level: Monitoring vancomycin peak or trough levels is important for toxicity prevention, but it is not the immediate priority during an acute hypersensitivity reaction.
- Nephrotoxicity: Elevated WBC or vancomycin trough does not indicate acute nephrotoxicity here, and the patient’s acute symptoms are consistent with an allergic reaction rather than kidney injury.
- Sepsis: Although the client has cellulitis and elevated WBCs, the sudden onset of hypotension, flushing, and respiratory distress after IV antibiotic administration is more indicative of anaphylaxis rather than sepsis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.5"]
Explanation
Calculation:
- Calculate the total dose in milligrams (mg).
Ordered dose: 0.02 mg/kg
Patient weight: 30 kg
Total dose (mg) = 0.02 mg/kg x 30 kg
= 0.6 mg.
- Calculate the volume to administer in milliliters (mL).
Total dose: 0.6 mg
Available concentration: 0.4 mg/mL
Volume (mL) = Total Dose (mg) / Available Concentration (mg/mL)
= 0.6 mg / 0.4 mg/mL
= 1.5 mL.
Correct Answer is B
Explanation
A. Nitroglycerin: Nitroglycerin is a vasodilator used to treat angina and does not have known interactions with vancomycin. Concurrent use does not increase the risk of vancomycin toxicity or adverse effects.
B. Furosemide: Furosemide is a loop diuretic that can be nephrotoxic and ototoxic, similar to vancomycin. Using both medications concurrently increases the risk of kidney damage and hearing loss, requiring careful monitoring of renal function and auditory status.
C. Calcium chloride: Calcium chloride is used for hypocalcemia and cardiac stabilization but does not interact directly with vancomycin. No enhanced toxicity or adverse reaction is expected when these drugs are administered together.
D. Morphine: Morphine is an opioid analgesic with no direct interaction with vancomycin. While both drugs may depress the central nervous system in different ways, morphine does not increase the risk of vancomycin-related nephrotoxicity or ototoxicity.
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