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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Rationale:

A. Thoroughly explain each procedure to the toddler: Toddlers have limited cognitive ability to understand detailed explanations. Overexplaining may cause anxiety rather than reassurance, especially if unfamiliar medical terms are used.

B. Allow the toddler to handle the equipment: Allowing the toddler to touch and explore safe medical equipment, like a stethoscope, helps reduce fear and builds trust. This play-based approach fosters cooperation and makes the exam less intimidating.

C. Completely undress the toddler: Toddlers can feel vulnerable when fully undressed. It is more appropriate to remove clothing gradually, only as needed for each part of the examination, to ensure comfort and security.

D. Start the examination with routine immunizations: Beginning with painful procedures like injections can create fear and resistance, making the rest of the exam more difficult. Immunizations should be done at the end of the visit.

A. Attempt to extinguish the fire before evacuating clients. B. Aim the spray of the fire extinguisher at the top of the fire. C. Open nearby doors and windows when the fire alarm sounds. D. Have ambulatory clients walk independently to a safe location

Correct Answer is D

Explanation

Rationale:

A. Attempt to extinguish the fire before evacuating clients: The priority is client safety. Attempting to extinguish a fire should only be done if the fire is small, contained, and the area has been cleared. Evacuation takes precedence over suppression efforts.

B. Aim the spray of the fire extinguisher at the top of the fire: The correct technique is to aim at the base of the fire to effectively cut off the fuel source. Aiming at the top will not extinguish the fire and may waste the extinguisher’s contents.

C. Open nearby doors and windows when the fire alarm sounds: Opening doors and windows can cause the fire to spread more rapidly by feeding it with oxygen. Doors should remain closed to help contain the fire and reduce the spread of smoke.

D. Have ambulatory clients walk independently to a safe location: Encouraging ambulatory clients to move independently helps prioritize assistance for those who are immobile or require more support. This approach ensures a quicker, safer evacuation process.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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