A nurse is evaluating a client's response after initiating an intermittent IV bolus of vancomycin. Which of the following findings indicates the client is experiencing an allergic reaction to the medication?
Hypertension
Dyspnea
Tetany
Headache
The Correct Answer is B
A. Hypertension: An allergic reaction to vancomycin typically does not cause high blood pressure. Blood pressure changes may occur with severe reactions, but hypertension is not a primary indicator.
B. Dyspnea: Difficulty breathing indicates a hypersensitivity or allergic reaction to vancomycin. Respiratory distress, along with potential hypotension, rash, or urticaria, signals the need for immediate intervention.
C. Tetany: Tetany is related to hypocalcemia or electrolyte imbalances, not vancomycin allergy. It is not an expected manifestation of an allergic response.
D. Headache: Headache is a nonspecific symptom and is not characteristic of an allergic reaction to vancomycin. It does not reliably indicate hypersensitivity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bradypnea: Opioid withdrawal typically causes an increase in respiratory rate rather than slowing. Bradypnea is more commonly associated with opioid intoxication, not withdrawal.
B. Constipation: While opioids cause constipation during use, withdrawal usually results in diarrhea and increased bowel motility rather than continued constipation.
C. Miosis: Pupil constriction occurs with opioid use. During withdrawal, pupils often dilate (mydriasis), so miosis is not expected.
D. Sneezing: Sneezing is a common manifestation of opioid withdrawal due to hyperactivity of the autonomic nervous system. Other signs include lacrimation, rhinorrhea, yawning, and generalized restlessness.
Correct Answer is ["B","C","G"]
Explanation
Rationale for correct choices:
- Sodium 124 mEq/L: The client’s serum sodium is critically low, indicating severe hyponatremia, a known serious adverse effect of oxcarbazepine. Hyponatremia can lead to confusion, seizures, and potentially life-threatening neurological complications, requiring immediate provider follow-up and possible medication adjustment or discontinuation.
- Difficulty remembering medication times: Cognitive changes or confusion may indicate central nervous system effects of oxcarbazepine or complications from hyponatremia. This finding signals the need for urgent reassessment and intervention to prevent medication errors or toxicity.
- Nausea/vomiting: Persistent nausea and vomiting, especially after a recent dose increase, may be a sign of drug intolerance, early hyponatremia symptoms, or central nervous system effects. Immediate follow-up is necessary to prevent further complications and dehydration.
Rationale for Incorrect Choices:
- Mild headache: While headaches may occur with oxcarbazepine, the mild nature and recent onset are less urgent compared with severe hyponatremia and neurological symptoms.
- Vital signs (HR 86, BP 110/66, Temp 36.3° C, RR 16): These are slightly lower than baseline but not immediately concerning. The priority is lab abnormality and neurological changes.
- Hct 40%, Hgb 13 g/dL: These values remain within normal limits and do not require immediate intervention.
- Use of oral contraceptives: This is important for counseling because oxcarbazepine can reduce contraceptive efficacy, but it is not an urgent clinical finding compared to hyponatremia.
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