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• Losartan: Losartan is an angiotensin II receptor blocker (ARB) used to lower blood pressure by relaxing blood vessels and reducing vascular resistance which is especially important for clients with high blood pressure.
• Moexipril: Moexipril is an angiotensin-converting enzyme (ACE) inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor.
• Metformin: Metformin is a first-line oral medication for type 2 diabetes. It decreases hepatic glucose production and improves insulin sensitivity in peripheral tissues. It is commonly prescribed for elevated fasting blood glucose and HbA1c.
• Liraglutide: Liraglutide is a GLP-1 receptor agonist that enhances glucose-dependent insulin secretion, slows gastric emptying, and promotes satiety. It is used to improve glycemic control and can aid in weight management in type 2 diabetes.

Rationale for correct choices:

• Sodium 124 mEq/L: The client’s serum sodium is critically low, indicating severe hyponatremia, a known serious adverse effect of oxcarbazepine. Hyponatremia can lead to confusion, seizures, and potentially life-threatening neurological complications, requiring immediate provider follow-up and possible medication adjustment or discontinuation.
• Difficulty remembering medication times: Cognitive changes or confusion may indicate central nervous system effects of oxcarbazepine or complications from hyponatremia. This finding signals the need for urgent reassessment and intervention to prevent medication errors or toxicity.
• Nausea/vomiting: Persistent nausea and vomiting, especially after a recent dose increase, may be a sign of drug intolerance, early hyponatremia symptoms, or central nervous system effects. Immediate follow-up is necessary to prevent further complications and dehydration.

Rationale for Incorrect Choices:

• Mild headache: While headaches may occur with oxcarbazepine, the mild nature and recent onset are less urgent compared with severe hyponatremia and neurological symptoms.
• Vital signs (HR 86, BP 110/66, Temp 36.3° C, RR 16): These are slightly lower than baseline but not immediately concerning. The priority is lab abnormality and neurological changes.
• Hct 40%, Hgb 13 g/dL: These values remain within normal limits and do not require immediate intervention.
• Use of oral contraceptives: This is important for counseling because oxcarbazepine can reduce contraceptive efficacy, but it is not an urgent clinical finding compared to hyponatremia.

Rationale for Correct Choices:

• Stop the IV infusion: The client is showing signs of a severe allergic reaction, including flushing, generalized itching, hypotension, tachycardia, hypoxia, and difficulty breathing shortly after vancomycin administration. Immediate cessation of the infusion is critical to prevent progression of anaphylaxis.
• Anaphylaxis: The client is exhibiting the classic signs of an anaphylactic-type reaction. The rapid infusion rate (325mL/hr) is very high for Vancomycin and often causes Red Man Syndrome, which is a histamine release reaction. However, the presence of difficulty breathing elevates this to anaphylactic or severe hypersensitivity reaction, requiring the most urgent response.

Rationale for Incorrect Choices:

• Administer epinephrine: Epinephrine is the first-line treatment for anaphylaxis, but it is administered after stopping the offending agent. Halting the infusion is the initial, priority nursing action.
• Request a serum peak drug level: Monitoring vancomycin peak or trough levels is important for toxicity prevention, but it is not the immediate priority during an acute hypersensitivity reaction.
• Nephrotoxicity: Elevated WBC or vancomycin trough does not indicate acute nephrotoxicity here, and the patient’s acute symptoms are consistent with an allergic reaction rather than kidney injury.
• Sepsis: Although the client has cellulitis and elevated WBCs, the sudden onset of hypotension, flushing, and respiratory distress after IV antibiotic administration is more indicative of anaphylaxis rather than sepsis.

Rationale for Correct Choices:

• Diltiazem: Diltiazem is a calcium channel blocker commonly used to control ventricular rate in atrial fibrillation. The client’s ECG confirms atrial fibrillation with rapid ventricular response, making rate control a priority to prevent hemodynamic instability.
• Cardiac rhythm: The rapid, irregular heart rate documented on ECG is the primary finding necessitating medication intervention to prevent further complications such as decreased cardiac output or thromboembolism.

Rationale for Incorrect Choices:

• Dopamine: Dopamine is a vasopressor used to support blood pressure in hypotension or shock. While the client’s BP is mildly decreased, the immediate concern is rapid atrial fibrillation rather than hypotensive crisis.
• Furosemide: Furosemide treats fluid overload and edema but does not directly address the acute arrhythmia causing tachycardia and hemodynamic compromise.
• Albuterol nebulizer: Albuterol is used for bronchospasm and respiratory distress related to airway constriction. The client has clear lung sounds, so this is not indicated.
• Alprazolam: Alprazolam can reduce anxiety but does not manage the underlying atrial fibrillation or prevent cardiovascular complications.
• Edema, blood pressure, anxiety, dyspnea: While these are relevant assessments, they are secondary to the urgent need to control the cardiac rhythm in acute atrial fibrillation.