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 D
Explanation
Choice A rationale:
Monitoring for hearing loss is not a specific action for primary syphilis. Hearing loss can occur in later stages of syphilis.
Choice B rationale:
Contact precautions are not typically required for primary syphilis, as it is primarily transmitted through sexual contact.
Choice C rationale:
Antiviral medications are not used to treat syphilis. Antibiotics are the primary treatment.
Choice D rationale:
Syphilis is a sexually transmitted infection that is required to be reported to the public health department for tracking and control.
Correct Answer is D
Explanation
Choice A rationale:
Sildenafil is typically taken as needed, not twice per day.
Choice B rationale:
Constipation is not a common adverse effect of sildenafil.
Choice C rationale:
Changing positions slowly after taking the medication is not related to sildenafil's mechanism of action.
Choice D rationale:
Sildenafil is a medication used to treat erectile dysfunction. Temporary visual changes, often described as a blue-green tinge or increased light sensitivity, are potential side effects of sildenafil due to its effect on the retinal enzyme.
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