A nurse is planning care for a client who is to receive a prescription for IV vancomycin. Which of the following interventions should the nurse include in the plan?
Examine the client's upper body for flushing of the skin during the infusion.
Monitor for hypertension while the medication infuses.
Check for a penicillin cross-sensitivity before infusing the medication.
Infuse the medication over 30 min.
The Correct Answer is A
A. Examine the client's upper body for flushing of the skin during the infusion: Red man syndrome is a common adverse effect of rapid IV vancomycin administration. It presents as flushing or rash on the upper body, and monitoring for this reaction is essential to ensure client safety.
B. Monitor for hypertension while the medication infuses: Vancomycin is more commonly associated with hypotension rather than hypertension during infusion, so monitoring for high blood pressure is not a primary concern.
C. Check for a penicillin cross-sensitivity before infusing the medication: Vancomycin is not a beta-lactam antibiotic, so penicillin allergy does not predict vancomycin reactions. Screening for cross-sensitivity is not required.
D. Infuse the medication over 30 min: Rapid infusion increases the risk of adverse effects such as red man syndrome. Vancomycin should typically be infused over at least 60 minutes or longer, depending on the dose, to reduce this risk.
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Related Questions
Correct Answer is C
Explanation
A. "I will limit my alcohol intake to two drinks per day.": Alcohol increases the risk of hepatotoxicity when combined with methotrexate. Clients should avoid alcohol completely rather than limiting intake.
B. "I should avoid eating foods that contain vitamin C.": Vitamin C does not worsen stomatitis or interact adversely with methotrexate. There is no need to avoid it in the diet.
C. "I should rinse my mouth with a warm salt solution.": Salt water rinses help soothe oral irritation, reduce bacterial growth, and promote healing of stomatitis, making this the appropriate action.
D. "I will continue to floss my teeth after each meal.": Flossing may irritate the oral mucosa further and worsen stomatitis, so clients should avoid it until the mucosa has healed.
Correct Answer is D
Explanation
A. Blood pressure 140/86 mm Hg: This blood pressure is slightly elevated but not indicative of an adverse reaction to morphine. Morphine more commonly causes hypotension rather than hypertension.
B. Heart rate 65/min: A heart rate of 65/min is within normal limits for most adults and does not signal a concerning response to morphine.
C. Temperature 37.5° C (99.5° F): This is a mild elevation within normal limits and is not associated with morphine administration.
D. Respiratory rate 10/min: Morphine can depress the central nervous system, leading to respiratory depression. A respiratory rate of 10/min is below the normal range (12–20/min) and indicates an adverse reaction requiring immediate monitoring and intervention.
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