A client who is receiving intravenous vancomycin reports feeling dizzy and flushed. The nurse observes that the client has a macular rash on the face and neck. Which of the following actions should the nurse take first?
Stop the infusion and notify the provider.
Administer diphenhydramine as prescribed.
Monitor the client's vital signs and oxygen saturation.
Slow down the infusion rate and observe for improvement.
The Correct Answer is A
A) This is correct because stopping the infusion and notifying the provider are the priority actions for a client who is experiencing signs and symptoms of anaphylaxis, which is a life-threatening allergic reaction to a medication. The nurse should also prepare to administer epinephrine as prescribed.
B) This is incorrect because administering diphenhydramine as prescribed is not the first action for a client who is experiencing anaphylaxis. Diphenhydramine is an antihistamine that can help relieve some symptoms of an allergic reaction, but it is not effective for reversing bronchoconstriction or hypotension that may occur in anaphylaxis.
C) This is incorrect because monitoring the client's vital signs and oxygen saturation is not the first action for a client who is experiencing anaphylaxis. Although these are important assessments, they are not as urgent as stopping the infusion and notifying the provider.
D) This is incorrect because slowing down the infusion rate and observing for improvement are not appropriate actions for a client who is experiencing anaphylaxis. Slowing down or continuing the infusion may worsen the client's condition and delay treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A) This is correct because using two client identifiers, such as name and date of birth, is a standard safety measure to ensure that the right medication is given to the right client.
B) This is correct because checking the expiration date of the medication before administering it is another safety measure to prevent giving expired or ineffective medications to clients.
C) This is correct because comparing the medication label with the prescription three times (before, during, and after preparing the medication) is a recommended practice to prevent errors such as wrong dose, wrong route, or wrong time.
D) This is incorrect because administering the medication as soon as possible after receiving it from the pharmacy may increase the risk of errors due to haste or distraction. The nurse should follow the prescribed schedule and administer the medication within a reasonable time frame.
E) This is incorrect because documenting the medication administration after completing other tasks may lead to forgetting or omitting important information. The nurse should document the medication administration as soon as possible after giving it to the client.
Correct Answer is D
Explanation
A) This is incorrect because discarding the vial and obtaining a new one is not necessary actions for a vial of insulin that has a small amount of white precipitate at the bottom. This precipitate indicates that the insulin has crystallized due to cold storage or temperature changes, but it can be resuspended by gently rolling or rotating the vial.
B) This is incorrect because shaking the vial vigorously until the precipitate dissolves is not an appropriate action for a vial of insulin that has a small amount of white precipitate at the bottom. Shaking the vial may cause air bubbles or froth to form, which can affect the accuracy of the dose measurement and administration.
C) This is incorrect because warming the vial in a microwave oven for a few seconds is not a safe action for a vial of insulin that has a small amount of white precipitate at the bottom. Warming the vial in a microwave oven may cause uneven heating or damage to the insulin molecules, which can alter the potency and effectiveness of the medication.
D) This is correct because rolling the vial gently between the palms of both hands is the recommended action for a vial of insulin that has a small amount of white precipitate at the bottom. Rolling the vial gently helps to resuspend the insulin crystals and restore the uniform appearance of the solution.
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