The nurse is caring for a patient who is receiving vancomycin (Vancocin). The nurse notes that the patient is experiencing flushing, rash, pruritus, and urticaria. The patient's heart rate is 120 beats per minute, and the blood pressure is 92/57 mm Hg. The nurse understands that these findings are consistent with:
allergic reaction.
rhabdomyolysis.
Stevens-Johnson syndrome.
red man syndrome.
The Correct Answer is D
Allergic reaction: An allergic reaction can manifest in various ways, including rash, itching, and difficulty breathing. However, the specific symptoms described, along with the context of vancomycin administration, point to red man syndrome in this case.
Rhabdomyolysis: Rhabdomyolysis is a condition where damaged muscle tissue breaks down and releases a protein called myoglobin into the bloodstream. This can cause kidney damage, but the symptoms described do not align with rhabdomyolysis.
Stevens-Johnson syndrome: Stevens-Johnson syndrome is a severe skin reaction that can cause skin and mucous membranes to blister, peel, and can be life-threatening. While it can present with rash and other skin symptoms, the symptoms mentioned in the scenario are more characteristic of red man syndrome.
Red man syndrome: As mentioned earlier, red man syndrome is an allergic reaction to vancomycin characterized by flushing, rash, pruritus, and urticaria (hives), along with rapid heart rate and low blood pressure. It is specific to vancomycin and can be prevented or minimized by slowing down the infusion rate and administering antihistamines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Neutrophils: Neutrophils are a type of white blood cell that plays a key role in the immune system's response to infections, particularly bacterial infections. They are not primarily involved in eliminating cancer cells.
B. Eosinophils: Eosinophils are another type of white blood cell. They are important in the immune response to parasites and are also involved in allergic reactions. While they have a role in the immune system, they are not the primary cells involved in eliminating cancer cells.
C. Platelets: Platelets, also known as thrombocytes, are not cells but rather small cell fragments. They are essential for blood clotting and do not directly participate in the immune response against cancer cells.
D. Macrophages: Macrophages are a type of white blood cell that are involved in the immune system's defense against cancer. They are phagocytes, which means they engulf and digest cellular debris, foreign substances, and cancer cells. Macrophages play a crucial role in the body's immune surveillance and response against cancer.
Correct Answer is B
Explanation
A. Seizures: Some antibiotics, especially cephalosporins, can lower the seizure threshold, increasing the risk of seizures, especially in individuals prone to seizures or those with a history of epilepsy.
B. Nephrotoxicity: Both cephalosporins and aminoglycosides have the potential to harm the kidneys. When used together, their nephrotoxic effects can be additive, increasing the risk of kidney problems in patients.
C. Hearing Loss: Aminoglycosides, a class of antibiotics that includes drugs like gentamicin, are well-known for their potential to cause hearing loss, especially when used in high doses or for prolonged periods. This effect is due to their toxic impact on the hair cells in the inner ear.
D. Hepatotoxicity: Hepatotoxicity refers to liver damage caused by medications. Some antibiotics, including certain cephalosporins, can have hepatotoxic effects, potentially harming the liver. Monitoring liver function is important when these drugs are used.
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