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 ["B","D"]
Explanation
A. Hypertension: Anaphylaxis often leads to a rapid drop in blood pressure (hypotension) rather than hypertension. Hypotension is a more common symptom because of the severe vasodilation that occurs during anaphylactic reactions.
B. Angioedema: Yes, angioedema is a common clinical manifestation of anaphylaxis. Angioedema involves swelling of the deeper layers of the skin, often around the eyes and lips. It can also affect the throat, which can be life-threatening due to airway obstruction.
C. Petechiae: Petechiae are small red or purple spots that appear on the skin and are caused by bleeding into the skin's tissues. They are not a typical manifestation of anaphylaxis.
D. Bronchospasm: Yes, bronchospasm is a hallmark clinical manifestation of anaphylaxis. It involves the sudden constriction of the airways, leading to difficulty in breathing and wheezing.
Correct Answer is D
Explanation
A. Cushing's Syndrome: This is a condition caused by prolonged exposure to high levels of cortisol, a hormone produced by the adrenal glands. It is not related to kidney transplant or immunosuppressive therapy.
B. Hypersensitivity Reaction Type I: Also known as an immediate hypersensitivity reaction or an allergy, this type of reaction involves the immune system's exaggerated response to an allergen. Symptoms can range from mild to severe and occur quickly after exposure to the allergen. While allergies can cause various symptoms, they do not specifically represent rejection of a transplanted organ.
C. Chronic Graft Versus Host Rejection: This term is commonly associated with bone marrow or stem cell transplants. It occurs when immune cells from the donated tissue recognize the recipient's body as foreign and attack various organs or tissues. This process typically happens over a more extended period and is not directly related to the scenario described.
D. Acute Host Versus Graft Rejection: This occurs when the recipient's immune system recognizes the transplanted organ as foreign and launches an immune response against it. It can happen shortly after transplantation if the recipient's immune system is not adequately suppressed. In this case, stopping immunosuppressive therapy can trigger acute rejection, leading to the failure of the transplanted organ.
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