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.

Answer and Explanation

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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Correct Answer is B

Explanation

A) Monitor the client's thyroid function levels: This action is not directly relevant to the administration error involving metformin instead of metoprolol. Metformin is not known to affect thyroid function levels. Monitoring thyroid function levels may be appropriate for clients taking certain medications, but it is not indicated in this situation.

B) Check the client's glucose level: Metformin is a medication commonly used to treat type 2 diabetes by lowering blood glucose levels. In this scenario, administering metformin instead of metoprolol could lead to hypoglycemia in the client if they do not have diabetes. Checking the client's glucose level is essential to assess for hypoglycemia and initiate appropriate treatment if necessary.

C) Obtain the client's HDL level: HDL (high-density lipoprotein) level measurement is not directly related to the administration error involving metformin. Metformin is not typically associated with significant effects on HDL levels. Monitoring HDL levels may be relevant for clients with specific cardiovascular risk factors but is not the priority in this situation.

D) Collect the client's uric acid level: Monitoring uric acid levels is not directly relevant to the administration error involving metformin. Metformin is not known to significantly affect uric acid levels. Assessing uric acid levels may be indicated for clients with conditions like gout, but it is not the primary concern in this scenario where the client received the wrong medication.

A. Black stools B. Dry cough C. Oral candidias D. Tardive dyskinesia

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.

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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?

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