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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale:

Asking the client to explain what she is hearing may not be helpful, as the client's perception of the hallucinations may not match reality.

Choice B rationale:

Conveying empathy is important to establish a therapeutic relationship and provide emotional support.

Choice C rationale:

Encouraging the client to listen to music through headphones can help distract from auditory hallucinations.

Choice D rationale:

Speaking simply and clearly when communicating helps the client understand and process information more effectively.

Choice E rationale:

Using therapeutic touch might not be appropriate for all clients and should be based on the client's preferences and comfort level.

A. Bulging fontanels B. Blue hands and feet C. Generalized petechiae D. Flaring of the nares

Correct Answer is B

Explanation

Choice A rationale:

Bulging fontanels are a sign of increased intracranial pressure, which is an abnormal finding in newborns. The nurse should assess for other signs of neurological impairment, such as lethargy, irritability, or seizures.

Choice B rationale:

Blue hands and feet, also known as acrocyanosis, are a normal finding in newborns who are 4 hr old. This is due to immature peripheral circulation and should resolve within 24 to 48 hr.

Choice C rationale:

Generalized petechiae are a sign of bleeding disorders, infection, or trauma, which are abnormal findings in newborns. The nurse should assess for other signs of bleeding, such as bruising, hematuria, or melena.

Choice D rationale:

Flaring of the nares is a sign of respiratory distress, which is an abnormal finding in newborns. The nurse should assess for other signs of respiratory distress, such as grunting, retractions, or cyanosis.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse plan to take? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A nurse is assessing a newborn who is 4 hr old. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client who is experiencing a crisis. Which of the following actions should the nurse take first?

A nurse is assessing a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?

A nurse is caring for a client who is suspected to have developed sensitivity to latex. Which of the following interventions should the nurse plan to implement?

A nurse is teaching a client who has a family history of pancreatic cancer about manifestations associated with the disease. Which of the following findings should the nurse include?

A nurse is providing teaching about varenicline to a client who is in a smoking cessation program. Which of the following statements should the nurse make?

A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a prescription for methylergonovine. Which of the following findings should the nurse identify as a contraindication to the administration of this medication?

A nurse is monitoring the laboratory values of a client who has rheumatoid arthritis and is taking methotrexate. Which of the following values should the nurse identify as an adverse effect of the medication?

A nurse is teaching a client who has a new diagnosis of diverticulitis. Which of the following instructions should the nurse include in the teaching?