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 A
Explanation
Choice A rationale:
Slurred speech could indicate a potential neurological complication in a client with sickle cell anemia, such as a stroke. Neurological symptoms require immediate attention and reporting to the healthcare provider.
Choice B rationale:
Yellowed sclera (jaundice) can be related to sickle cell anemia but is less acutely concerning than slurred speech.
Choice C rationale:
Ulcers on the ankles are often associated with sickle cell anemia, but they are not as urgent as neurological symptoms.
Choice D rationale:
Swelling in the joints is a potential manifestation of sickle cell anemia, but slurred speech indicates a more acute and concerning issue.
Correct Answer is C
Explanation
Choice A rationale:
Increased serum amylase is a common finding in acute pancreatitis, and its decrease would be a positive sign. However, lipase is a more specific marker for pancreatic injury.
Choice B rationale:
Increased C-reactive protein is a marker of inflammation and would not necessarily indicate improvement in pancreatitis.
Choice C rationale:
Decreased serum lipase indicates improvement in the pancreatic injury and is a positive sign.
Choice D rationale:
Decreased platelets would not specifically indicate improvement in acute pancreatitis.
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