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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Pain level: Assessing the client's pain level may be important for administering analgesic medications, but it is not directly related to the administration of propranolol. Propranolol is a beta-blocker primarily used to treat conditions such as hypertension, angina, and certain cardiac arrhythmias, so assessing pain level is not the priority.
B) Respiratory rate: While monitoring respiratory rate is important in various clinical situations, propranolol administration does not typically have a direct effect on respiratory function. Therefore, assessing the respiratory rate specifically before administering propranolol may not be as relevant as other vital signs.
C) Heart rate: Propranolol is a beta-blocker that primarily works by slowing the heart rate and reducing the workload on the heart. Therefore, it is crucial for the nurse to assess the client's heart rate prior to administering propranolol to ensure it is within the appropriate range. Administering propranolol to a client with bradycardia or a significantly low heart rate could exacerbate this condition and lead to adverse effects.
D) Temperature: While monitoring temperature is important for assessing for signs of infection or other systemic issues, it is not directly relevant to the administration of propranolol. Propranolol primarily affects cardiovascular function, so assessing temperature is not typically a priority before administering this medication
Correct Answer is A
Explanation
) Glaucoma: Atropine is contraindicated in clients with glaucoma due to its potential to exacerbate intraocular pressure. Glaucoma is a condition characterized by increased intraocular pressure, which can lead to optic nerve damage and vision loss if left untreated or if pressure is further increased. Atropine, as an anticholinergic medication, works by dilating the pupil and inhibiting accommodation, thereby increasing intraocular pressure. Administering atropine to a client with glaucoma can worsen their condition and potentially cause acute angle-closure glaucoma, which is a medical emergency. Therefore, it is essential to avoid using atropine in clients with glaucoma to prevent irreversible vision loss and other serious complications.
B) Bronchospasms: Atropine can be used to treat bronchospasms by dilating the bronchi and bronchioles, making it easier to breathe. While it may not be the first-line treatment for bronchospasms, it is not contraindicated in this condition. The bronchodilatory effects of atropine help relieve airway constriction and improve airflow, which can be beneficial in managing bronchospasms associated with conditions such as asthma or chronic obstructive pulmonary disease (COPD). Therefore, atropine can be considered as part of the treatment regimen for bronchospasms when indicated.
C) Diverticulitis: Atropine does not have any specific contraindications related to diverticulitis. However, caution should be exercised in clients with pre-existing gastrointestinal conditions due to potential anticholinergic effects, such as decreased gastrointestinal motility. While atropine can inhibit gastrointestinal motility and secretions, which may exacerbate symptoms in some individuals with diverticulitis, it is not considered a contraindication. The decision to use atropine in clients with diverticulitis should be based on the overall assessment of the client's condition and the potential benefits versus risks of treatment.
D) Diarrhea: Atropine can be used to treat diarrhea by reducing gastrointestinal motility and secretions. Therefore, it is not contraindicated in clients with diarrhea. By slowing down gastrointestinal motility and reducing secretions, atropine can help alleviate diarrhea and promote better bowel control. While other treatment options may be considered depending on the underlying cause of diarrhea, atropine can be effective in managing diarrhea associated with certain conditions or as part of a treatment regimen for specific gastrointestinal disorders.
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.