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 A
Explanation
A. "This drug has a longer duration of action than some of the other antibiotics."
Explanation: Azithromycin, a macrolide antibiotic, has a longer half-life in the body compared to some other antibiotics. Half-life refers to the time it takes for half of the drug to be eliminated from the body. A longer half-life means the drug remains effective for a longer duration, allowing for less frequent dosing.
B. "This is a much more effective drug than what you received previously."
Explanation: While azithromycin is effective against a wide range of bacterial infections, it's not accurate to say it's universally more effective than other antibiotics. The choice of antibiotic depends on the specific type of infection and the susceptibility of the bacteria causing it. Effectiveness varies based on the context of use.
C. "I'll call the pharmacy and ask about the chemical makeup of the drug."
Explanation: While understanding the chemical makeup of drugs is important for healthcare professionals, it might not directly answer the patient's question about the dosing frequency. Explaining the drug's pharmacological properties, such as its duration of action, would provide a more relevant and understandable response to the patient's query.
D. "You'll need to ask your healthcare provider questions like that."
Explanation: This response does not provide the patient with the information they seek. Nurses are valuable resources for medication-related questions and should strive to provide accurate and understandable explanations to patients.
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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