A nurse is caring for a client who is receiving an initial dose of vancomycin IV. The client begins experiencing dyspnea and swelling of the face. After discontinuing the vancomycin infusion, which of the following actions should the nurse take next?
Call the rapid response team.
Prepare the client for intubation.
Obtain an ABG level.
Administer diphenhydramine.
The Correct Answer is A
Choice A rationale:
The client is experiencing signs of an allergic reaction or anaphylaxis, which can be life-threatening. The rapid response team should be called to provide immediate medical assistance.
Choice B rationale:
Intubation is not the immediate priority. Addressing the allergic reaction and ensuring the client's airway, breathing, and circulation are the first steps.
Choice C rationale:
Obtaining an arterial blood gas (ABG) level is not the priority when the client is experiencing respiratory distress and facial swelling.
Choice D rationale:
Administering diphenhydramine may be part of the treatment plan, but the immediate priority is to call for emergency assistance to manage the allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A slightly elevated WBC count is not a contraindication for the administration of methylergonovine.
Choice B rationale:
Methylergonovine can cause vasoconstriction and bronchoconstriction, which can exacerbate asthma symptoms. Therefore, a history of asthma is a contraindication for its use.
Choice C rationale:
Hgb of 11.2 g/dL is within an acceptable range and not a contraindication for methylergonovine.
Choice D rationale:
Blood pressure of 154/98 mm Hg is elevated, but it is not a contraindication for the administration of methylergonovine.
Correct Answer is C
Explanation
A: Expecting heavier menstrual bleeding while using the patch is not a typical instruction given to clients. The patch may actually result in lighter, more regular bleeding.
B: The patch should not be placed on the upper thigh. According to the guidelines, the patch should be applied to clean, dry skin on the belly, buttocks, or back, and can also be placed on the outer part of the upper arm.
C: Applying the first patch within 24 hours of starting the menstrual cycle is correct. This ensures that the patch begins to work in sync with the client's natural cycle, providing immediate contraceptive protection.
D: A new patch should not be applied at the same time each day. Instead, it should be changed once a week on the same day, known as the "patch change day" to maintain consistent contraceptive coverage.
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