A nurse is caring for a client who has acute pancreatitis. After treating the client’s pain, which of the following should the nurse address as the priority intervention?

Choice A reason:

Decreasing the infusion rate is the appropriate action when a client experiences flushing and tachycardia while receiving IV vancomycin. These symptoms are indicative of “Red Man Syndrome,” a reaction that occurs when vancomycin is infused too quickly. Slowing the infusion rate can help alleviate these symptoms and prevent further complications.

Choice B reason:

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

Choice C reason:

Documenting that the client experienced an anaphylactic reaction to the medication is incorrect. Anaphylaxis is a severe, life-threatening allergic reaction that involves symptoms such as difficulty breathing, swelling of the face and throat, and a rapid drop in blood pressure. The symptoms described (flushing and tachycardia) are more consistent with Red Man Syndrome, not anaphylaxis.

Choice D reason:

Applying cold compresses to the neck area is not an effective intervention for managing the symptoms of Red Man Syndrome. The primary approach should be to slow the infusion rate of vancomycin. Cold compresses would not address the cause of the reaction.

Choice A reason: Babinski’s sign

Babinski’s sign is a reflex action where the big toe moves upward or toward the top surface of the foot and the other toes fan out when the sole of the foot is stimulated. This sign is used to assess neurological function, particularly in the context of central nervous system disorders. It is not related to hypocalcemia, which is the likely cause of the tingling sensation in this scenario.

Choice B reason: Chvostek’s sign

Chvostek’s sign is a clinical indicator of hypocalcemia. It is elicited by tapping the facial nerve at the angle of the jaw, which causes twitching of the facial muscles. Hypocalcemia is a common complication following thyroidectomy due to potential damage or removal of the parathyroid glands, which regulate calcium levels. The tingling sensation reported by the client is a classic symptom of hypocalcemia, making Chvostek’s sign the most relevant assessment.

Choice C reason: Brudzinski’s sign

Brudzinski’s sign is used to assess for meningitis. It involves flexing the client’s neck and observing for involuntary flexion of the hips and knees. This sign is not related to hypocalcemia or the symptoms described by the client following thyroidectomy.

Choice D reason: Kernig’s sign

Kernig’s sign is another test for meningitis. It involves flexing the client’s hip and knee, then straightening the knee. Pain and resistance to straightening the knee indicate a positive Kernig’s sign. This sign is not relevant to the assessment of hypocalcemia or the symptoms described by the client.