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:
Referring the client to crisis intervention services might be necessary, but before doing so, the nurse should gather information to understand the client's current situation and coping mechanisms.
Choice B rationale:
Assessing the client's previous coping methods helps the nurse understand the client's strengths and provides insights into potential strategies for managing the crisis effectively.
Choice C rationale:
Discussing the cause of the crisis might be helpful, but it's important to first assess the client's current coping abilities and resources.
Choice D rationale:
Assisting the client in developing strategies to overcome the crisis is important, but it should come after a thorough assessment of the client's current coping mechanisms and situation.
Correct Answer is B
Explanation
Choice A rationale:
Waiting until school age to engage in social activities is not appropriate, as social interaction is important for a toddler's development.
Choice B rationale:
Interacting with the child according to their developmental age is important for fostering appropriate growth and development.
Choice C rationale:
Devoting more time to learning than playing may not be appropriate, as play is an essential component of early childhood development.
Choice D rationale:
Teaching several steps of a task at one time may be overwhelming for a toddler with a cognitive delay. Instructions should be simple and broken down into manageable steps.
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