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 A

Explanation

Rationale:

A. "I will place a night light in the hallway near the bathroom.": Installing night lights in commonly used paths, such as the hallway to the bathroom, helps prevent falls by improving visibility during nighttime trips, which is especially important for older adults with limited vision or balance.

B. "I will use a standard height toilet seat.": Standard height toilet seats can make sitting and standing more difficult for older adults. Raised toilet seats are safer and reduce the risk of falls by minimizing the effort required to use the toilet.

C. "I will set my water heater to 145 degrees Fahrenheit.": This temperature is too high and increases the risk of scald injuries. Water heaters should be set to no more than 120°F to protect older adults from accidental burns, as their skin is often thinner and more sensitive.

D. "I will cover extension cords with throw rugs.": Covering cords with rugs creates a tripping hazard. Extension cords should be secured against walls or removed altogether to reduce fall risk, especially in homes with elderly residents.

A. Beefy, red tongue B. Productive cough with thick mucous C. Facial erythema D. Koplik spots

Correct Answer is C

Explanation

Rationale:

A. Beefy, red tongue: A beefy, red tongue is typically associated with scarlet fever, not pertussis. It results from the streptococcal infection and accompanying inflammatory response, which is unrelated to the bacterial cause and symptom pattern of pertussis.

B. Productive cough with thick mucous: Pertussis, or whooping cough, usually causes a paroxysmal, dry, hacking cough followed by a characteristic "whooping" sound on inspiration. It is not commonly associated with a productive cough containing thick mucus, especially in early and peak stages.

C. Facial erythema: Facial erythema can occur during severe coughing fits in children with pertussis due to the forceful and prolonged nature of coughing episodes. The increased intrathoracic pressure during coughing may lead to flushing or redness of the face.

D. Koplik spots: Koplik spots are small, bluish-white lesions on the buccal mucosa and are an early sign of measles, not pertussis. They are not present in bacterial infections like Bordetella pertussis, which affects the respiratory tract.

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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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