A nurse is caring for a client who is receiving vancomycin by IV infusion over 30 min. Which of the following findings indicate the clien experiencing a vancomycin infusion reaction?
The client has an increased creatinine level.
The client is experiencing hypotension.
The client's IV site is red and edematous.
The c’ient reports ringing in their ears.
The Correct Answer is B
A) The client has an increased creatinine level: While an increased creatinine level may indicate renal impairment, it is not specific to a vancomycin infusion reaction. Elevated creatinine levels may occur due to various factors, including underlying kidney disease or dehydration.
B) The client is experiencing hypotension: This is the correct answer. Hypotension, or low blood pressure, can be a manifestation of a vancomycin infusion reaction. Vancomycin infusion reactions may include anaphylaxis or anaphylactoid reactions, which can lead to systemic vasodilation and subsequent hypotension.
C) The client's IV site is red and edematous: Redness ’nd edema at the IV site may indicate phlebitis or infiltration, which are local complications rather than systemic reactions to vancomycin infusion.
D) The client reports ringing in their ears: Ringing in the ears, also known as tinnitus, is a potential side effect of vancomycin, particularly with high doses or prolonged use. However, it is not specific to a vancomycin infusion reaction and may occur independently of the infusion process.
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Related Questions
Correct Answer is D
Explanation
A) Black stools: While black stools can be a potential side effect of gastrointestinal bleeding, it is not commonly associated with high-dose metoclopramide. This side effect is more commonly seen with medications such as aspirin or NSAIDs. Therefore, it is not the most pertinent adverse effect to monitor for with high-dose metoclopramide.
B) Dry cough: Dry cough is not a typical adverse effect of metoclopramide. Cough is more commonly associated with medications such as ACE inhibitors. Therefore, it is not the primary adverse effect to monitor for with high-dose metoclopramide.
C) Oral candidiasis: While oral candidiasis (oral thrush) can occur as a side effect of some medications, it is not commonly associated with metoclopramide. Oral candidiasis is more frequently seen with corticosteroids or antibiotics. Therefore, it is not the primary adverse effect to monitor for with high-dose metoclopramide.
D) Tardive dyskinesia: Tardive dyskinesia is a serious adverse effect associated with prolonged use of edicaopramide, especially at high doses. It is characterized by involuntary, repetitive movements of the face, tongue, or other parts of the body. Monitoring for signs and symptoms of tardive dyskinesia, such as repetitive facial grimacing or tongue protrusion, is crucial when administering high-dose metoclopramide to prevent this potentially irreversible condition. Therefore, this is the correct adverse effect to monitor for in clients receiving high-dose metoclopramide.
Correct Answer is C
Explanation
A) Elevate the extremity: This action helps reduce swelling and minimizes the spread of infiltrated fluid into surrounding tissues by using gravity to assist in draining the excess fluid back into the bloodstream. Elevating the affected limb above the level of the heart promotes venous return and can help prevent further tissue damage.
B) Flush the IV catheter: Flushing the IV catheter could exacerbate infiltration by pushing more fluid into the surrounding tissue. It is not the appropriate action for managing infiltration and could worsen the client's condition.
C) Slow the infusion rate: Slowing the infusion rate is a reasonable action to reduce the flow of fluid into the tissues and minimize further infiltration. However, it may not be sufficient to manage existing infiltration effectively or prevent tissue damage.
D) Apply pressure to the IV site: Applying pressure to the IV site is not recommended for managing infiltration. It could cause further tissue damage and discomfort for the client and is not considered a standard practice in managing this complication.
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