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.

Answer and Explanation

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.

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Correct Answer is {"xRanges":[299.765625,329.765625],"yRanges":[366.609375,396.609375]}

Explanation

Choice A rationale: This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation).

Choice B rationale: This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation). It then decreases steadily at approximately 1 cm every 24 hours.

Choice C rationale: One-week post-partum, the fundal height should be about 7 cm below the umbilicus (belly button). This means that the uterus is still larger than normal, but it is contracting and healing. The fundal height may vary depending on factors such as the size and position of the baby, the amount of amniotic fluid, and the mother's body type.

A. "We can give your child all of the missed immunizations in one injection." B. "Your child will have to start their immunization series over from the beginning." C. "We will administer the immunizations your child missed today." D. "We will give your child all of the needed immunizations at 12 months."

Correct Answer is C

Explanation

Choice A rationale:

Administering all the missed immunizations in one injection is not recommended and can lead to increased discomfort and potential adverse reactions.

Choice B rationale:

Starting the immunization series over is unnecessary and can delay the child's protection against vaccine-preventable diseases.

Choice C rationale:

The most appropriate action is to administer the immunizations the child missed at the earliest opportunity to catch up on the schedule.

Choice D rationale:

Waiting until 12 months of age is not necessary if the child has already missed scheduled immunizations. The catch-up schedule should be followed based on the child's current age.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 1 week postpartum. Which of the following locations should the nurse palpate to assess the client's fundus? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is {"xRanges":[299.765625,329.765625],"yRanges":[366.609375,396.609375]}

Explanation

A nurse is caring for a 9-month-old infant in a pediatric clinic. The child's guardian tells the nurse that the child has missed the scheduled 6-month immunizations. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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