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:
Children with autism spectrum disorder often have difficulty with transitions and new situations. Introducing new situations slowly can help reduce anxiety and support a smoother adjustment.
Choice B rationale:
Administering valproic acid is not a nursing intervention for autism spectrum disorder.
Choice C rationale:
Allowing the toddler to choose the daily routine might not be effective as they may struggle with decision-making and may prefer structured routines.
Choice D rationale:
Increasing stimulation in the toddler's environment might overwhelm a child with autism, who often prefers a calm and predictable environment.
Correct Answer is A
Explanation
Choice A rationale:
Somatropin can affect glucose metabolism and may lead to hypoglycemia. Parents should be aware of this potential side effect and monitor their child's blood sugar levels.
Choice B rationale:
Somatropin is usually administered via injection, not under the tongue.
Choice C rationale:
Ringing in the ears is not a common side effect of somatropin.
Choice D rationale:
Monitoring height monthly is important, but explaining the potential for hypoglycemia is more relevant to the immediate safety of the child.
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