Exhibits
The nurse would determine what actions to implement in an emergent situation. Drag from Word Choices to complete the sentence.
The client is at immediate risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"B"}
A. anaphylaxis
The correct answer is A. Anaphylaxis is a severe, life-threatening allergic reaction that can occur in response to medication administration. The client's symptoms of dizziness, headache, burning feeling on extremities, and redness on face and extremities, along with the sudden onset of symptoms after starting vancomycin infusion, are indicative of a possible anaphylactic reaction.
B. arrhythmias
The correct answer is B. Arrhythmias refer to abnormal heart rhythms, which can be
triggered by various factors including medication reactions. Given the client's history of symptomatic bradycardia and the sudden onset of symptoms after starting vancomycin infusion, arrhythmias such as bradycardia or other rhythm disturbances are a concern.
C. Cardiac arrest
The correct answer is C. Cardiac arrest is the cessation of normal heart function, which can be precipitated by severe arrhythmias or anaphylaxis. The client's symptoms, along with the drop in blood pressure, indicate a potential risk of progressing to cardiac arrest if not promptly treated.
D. Necrosis
Necrosis, or tissue death, is not typically associated with the symptoms described in the scenario. While vancomycin infusion can potentially cause tissue irritation or damage at the
injection site, the symptoms described suggest a systemic reaction rather than localized tissue necrosis.
E. Renal failure
Renal failure is not directly indicated by the symptoms described in the scenario. While vancomycin can be nephrotoxic in some cases, the symptoms of dizziness, headache, and redness are more suggestive of an allergic or cardiovascular reaction.
F. Peripheral edema
Peripheral edema, or swelling in the extremities, is not indicated by the symptoms described in the scenario. The client's symptoms, such as dizziness, headache, and redness, are more
indicative of a systemic reaction rather than localized swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Currently prescribed medications are important information, but in this emergent situation, the nurse should first report on the client's condition and immediate concerns.
B. Falling from a ladder as the reason for admission is relevant information, but it does not address the immediate clinical concern of the client's altered mental status.
C. Reporting the increasing confusion of the client is the priority as it highlights the acute change in neurological status, which may indicate a more critical issue such as intracranial injury or neurological impairment.
D. The client's healthcare power of attorney is important for long-term care planning, but it is not the immediate concern when the client presents with altered mental status and potential head
trauma.
Correct Answer is D
Explanation
A. Gastric Irritation.
While gastric irritation is a common side effect of prednisone, it is not as critical as some other potential adverse effects and can often be managed with medication or dietary changes.
B. Moon facies.
Moon facies is a sign of Cushing's syndrome, a potential long-term side effect of prednisone, but it does not require immediate reporting compared to more acute symptoms.
C. Abdominal striae.
Abdominal striae (stretch marks) are a long-term side effect of corticosteroids like prednisone, but they are not typically an urgent concern.
D. Rapid weight gain.
This is the correct answer because rapid weight gain can indicate fluid retention, which may be a sign of more serious side effects such as heart failure or severe hypertension. It requires prompt medical attention to prevent further complications.
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