A nurse is administering intravenous vancomycin to a patient with a serious infection.
Which of the following signs should prompt the nurse to immediately intervene and notify the healthcare provider?
The patient experiences phlebitis at the IV site with mild redness and tenderness.
The patient develops flushing, hypotension, and wheezing during the infusion.
The patient complains of mild tinnitus but has stable vital signs.
The patient reports mild myalgia and vertigo after the infusion.
The Correct Answer is B
This question tests clinical judgment regarding life-threatening adverse reactions to vancomycin. It requires identifying the signs of an anaphylactic or severe infusion-related reaction, which necessitates immediate intervention to maintain the patient's airway, breathing, and circulation, as these symptoms indicate critical physiological instability.
Choice A rationale
Phlebitis is a localized inflammatory reaction of the vein wall. While it requires assessment and site rotation to prevent further tissue damage, it is a localized complication and does not represent a life-threatening systemic emergency.
Choice B rationale
Flushing, hypotension, and wheezing are cardinal signs of an anaphylactic reaction. These systemic symptoms indicate severe bronchospasm and cardiovascular collapse, requiring immediate cessation of the infusion, administration of epinephrine, and urgent medical management to prevent patient mortality.
Choice C rationale
Mild tinnitus is a known side effect related to vancomycin's potential ototoxicity, which is usually dose-related and progressive. While it warrants monitoring and potential dose adjustment, it does not represent an immediate systemic emergency that requires emergency intervention.
Choice D rationale
Mild myalgia and vertigo can occur following vancomycin administration but are not indicative of an immediate, life-threatening crisis. They require monitoring and documentation, but the patient remains hemodynamically stable, making this a secondary priority compared to anaphylaxis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This question tests clinical recognition of a severe hypersensitivity response to a medication. It requires identifying the systemic symptoms of anaphylaxis, which is a life-threatening, IgE-mediated immune reaction that necessitates immediate emergency medical intervention and the permanent discontinuation of the offending antibiotic.
Choice A rationale
Tolerance refers to a decreased physiological response to a medication after repeated exposure. The patient's symptoms are acute signs of an immune-mediated hypersensitivity reaction, not a reduction in the therapeutic or side-effect response to the antibiotic medication.
Choice B rationale
Clostridium difficile is a bacterial infection of the colon often caused by antibiotic therapy due to the disruption of normal intestinal flora. It typically presents with severe diarrhea, not acute systemic allergic symptoms like hives or tongue swelling.
Choice C rationale
A superinfection is a new infection that develops during treatment for a primary infection, often due to the eradication of protective commensal bacteria. These infections involve the growth of resistant organisms and do not manifest as immediate, systemic anaphylactic reactions.
Choice D rationale
The constellation of flushing, itching, hives, anxiety, and tongue swelling is characteristic of an anaphylactic reaction. This systemic, IgE-mediated response can progress rapidly to airway obstruction and circulatory collapse, requiring immediate administration of epinephrine and supportive medical care.
Correct Answer is B
Explanation
This question addresses the emergency management of opioid-induced respiratory depression. The nurse must recognize signs of overdose, specifically bradypnea (normal rate 12 to 20 breaths/minute), and act immediately to administer a specific pharmacological antagonist to reverse opioid receptor binding and restore stable respiratory function.
Choice A rationale
Oxygen administration provides supportive care but does not address the underlying cause of respiratory depression. Opioids must be reversed at the receptor level to restore the brain's drive to breathe, making oxygen a secondary intervention in an acute opioid toxicity crisis.
Choice B rationale
Naloxone is a competitive opioid antagonist that rapidly displaces opioids from receptors. It is the specific antidote for morphine-induced respiratory depression and will restore the patient's normal respiratory rate and prevent further hypoxemia and the risk of cardiac arrest.
Choice C rationale
Flumazenil is the specific antidote for benzodiazepine overdose. It has no pharmacological effect on opioid receptors and would be completely ineffective in reversing the respiratory depression caused by morphine, leaving the patient at high risk for ongoing respiratory failure.
Choice D rationale
Intubation is reserved for cases where pharmacological reversal fails or the airway cannot be protected. In this acute opioid overdose, administration of naloxone is the first-line intervention that can quickly reverse the respiratory depression without the risks associated with invasive intubation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.