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:
Phenytoin should be administered slowly to avoid adverse effects. Infusing 800 mg over 5 minutes is too rapid and can lead to cardiovascular complications.
Choice B rationale:
Rationale: After administering phenytoin via IV, it's important to flush the IV line with normal saline (0.9% sodium chloride) to ensure the medication is fully delivered to the client and to prevent any residual medication from precipitating in the IV line.
Choice C rationale:
Flushing with heparin is not standard practice for administering phenytoin.
Choice D rationale:
Phenytoin should be administered in normal saline, not in D5W (dextrose 5% in water), to avoid precipitation.
Correct Answer is C
Explanation
Choice A rationale:
Restricting fluid intake is not the primary concern when taking lithium. It's more important to maintain a consistent level of sodium intake.
Choice B rationale:
Doubling the dose of lithium without medical supervision can lead to lithium toxicity, which can be life-threatening.
Choice C rationale:
Sodium levels can impact the effectiveness and safety of lithium. Consuming a moderate- sodium diet helps prevent sodium depletion or overload, which can affect lithium levels.
Choice D rationale:
Slurred speech is not indicative of low lithium levels. It's important to monitor for signs of lithium toxicity, which include tremors, confusion, and GI symptoms.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.