The nurse is assisting in the administration of IV vancomycin to a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings indicate an allergic reaction to the medication?
Hypertension
Headache
Tinnitus
Urticaria
The Correct Answer is D
Rationale:
A. Hypertension: Hypertension is not typically associated with an allergic reaction to vancomycin. Hypotension may occur in severe reactions like "red man syndrome," but elevated blood pressure is generally unrelated to allergic responses.
B. Headache: Headache is a possible side effect of many medications, including vancomycin, but it does not specifically indicate an allergic reaction. It is a nonspecific symptom and usually does not warrant discontinuation unless severe.
C. Tinnitus: Tinnitus is a sign of ototoxicity, a known adverse effect of vancomycin, especially with high doses or prolonged use. However, it is not indicative of an allergic reaction but rather toxicity affecting the auditory system.
D. Urticaria: Urticaria, or hives, is a classic manifestation of an allergic reaction involving histamine release causing itchy, raised, red skin lesions. Its presence during vancomycin administration signals hypersensitivity and requires immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Cleanse the perineum with 0.9% sodium chloride after bowel movements: While perineal hygiene is important postpartum, cleansing with normal saline is more routine care and does not specifically target endometritis management.
B. Obtain serial blood cultures: Endometritis is a uterine infection that can lead to bacteremia or sepsis. Serial blood cultures help identify the causative organism and guide antibiotic therapy.
C. Insert and maintain an indwelling urinary catheter: Indwelling catheters increase the risk of urinary tract infections and are not routinely used unless there is urinary retention or other specific indications.
D. Encourage the use of a sitz bath twice a day: Sitz baths promote perineal comfort and hygiene but do not directly treat uterine infections like endometritis. They may be recommended for perineal pain but are not primary treatment for endometritis.
Correct Answer is D
Explanation
Rationale:
A. Tonic-clonic seizures: Tonic-clonic activity is induced during the ECT procedure itself but typically resolves within seconds. It is not expected to persist 15 minutes post-procedure, as seizure activity is carefully controlled and monitored during the treatment.
B. Sleep apnea: While general anesthesia used during ECT can cause brief respiratory depression, sleep apnea is not a typical or expected consequence of the procedure. Continuous monitoring ensures airway patency during and immediately after treatment.
C. Paresthesias: Numbness or tingling sensations (paresthesias) are not common side effects of ECT. The procedure affects brain activity and cognition rather than peripheral nerves, making this symptom unlikely post-treatment.
D. Disorientation: Temporary confusion or disorientation is a common and expected side effect shortly after ECT. It typically resolves within 30 to 60 minutes as the effects of anesthesia wear off, and it is routinely monitored during recovery.
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