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. Respiratory Function: Monitoring respiratory function is important for conditions like asthma or chronic obstructive pulmonary disease (COPD). It involves assessing lung sounds, oxygen saturation levels, and breathing patterns. This monitoring is essential to detect any signs of respiratory distress.
B. Cardiac Function: Monitoring cardiac function includes assessing heart rate, blood pressure, and rhythm. It's crucial for patients with heart conditions like heart failure or arrhythmias. This monitoring helps in identifying irregularities in heart function and provides insights into the overall cardiovascular health of the patient.
C. Renal Function: Monitoring renal function involves assessing kidney health, which includes tests like serum creatinine and glomerular filtration rate (GFR). This is vital for patients with kidney diseases or those taking medications that can impact kidney function. Monitoring renal function helps in detecting any signs of kidney impairment or failure.
D. Liver Function: Monitoring liver function involves tests like liver enzymes (AST, ALT), bilirubin levels, and albumin levels. This is essential for patients taking medications that can affect the liver, such as certain antifungals, statins, or pain relievers. Monitoring liver function helps in identifying liver damage or dysfunction early on.
Correct Answer is A
Explanation
A. Ototoxicity and Nephrotoxicity:
Ototoxicity: Aminoglycosides can damage the inner ear structures, leading to hearing loss and balance issues.
Nephrotoxicity: These drugs can harm the kidneys, potentially causing acute kidney injury or chronic kidney disease. Monitoring kidney function is crucial to prevent renal damage.
B. Ototoxicity and Cardiotoxicity:
Ototoxicity: As mentioned above, aminoglycosides can damage the inner ear, affecting hearing and balance.
Cardiotoxicity: Aminoglycosides primarily affect the ears and kidneys; they do not directly target the heart. Cardiotoxicity is not a common side effect associated with aminoglycosides.
C. Hepatotoxicity and Nephrotoxicity:
Hepatotoxicity: This term refers to liver damage caused by drugs or toxins. Aminoglycosides are not known to cause liver problems; their primary concern is kidney damage.
Nephrotoxicity: As mentioned earlier, aminoglycosides can harm the kidneys, which is a well-known side effect.
D. Cardiotoxicity and Hepatotoxicity:
Cardiotoxicity: This term refers to the toxic effects on the heart, leading to various heart-related issues. Aminoglycosides do not primarily affect the heart; their main concerns are the ears (ototoxicity) and kidneys (nephrotoxicity).
Hepatotoxicity: Aminoglycosides are not typically associated with liver damage. They are primarily metabolized and excreted by the kidneys, which is why kidney monitoring is crucial during their use.
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