A nurse is assessing a client after administering IV vancomycin. Which of the following findings is the nurse's priority to report to the provider?

Client report of a headache

Audible inspiratory stridor

Client report of tinnitus

Localized redness at the catheter insertion site

Answer and Explanation

The Correct Answer is B

Choice A reason: Client report of a headache is not the nurse's priority to report to the provider. A headache is a common and mild side effect of vancomycin, which is an antibiotic used to treat serious infections. A headache may be caused by dehydration, stress, or other factors, and can be relieved by drinking fluids, resting, or taking analgesics.

Choice B reason: Audible inspiratory stridor is the nurse's priority to report to the provider. Stridor is a high-pitched, wheezing sound that occurs when breathing in, and indicates a narrowing or obstruction of the airway. Stridor may be a sign of a severe allergic reaction, or anaphylaxis, to vancomycin, which can be life-threatening. Anaphylaxis can also cause swelling of the face, lips, tongue, or throat, difficulty breathing, low blood pressure, and shock. The nurse should stop the infusion, administer epinephrine, and monitor the client's vital signs.

Choice C reason: Client report of tinnitus is not the nurse's priority to report to the provider. Tinnitus is a ringing or buzzing sound in the ears, and may be a rare and serious side effect of vancomycin. Tinnitus may indicate damage to the inner ear, or ototoxicity, which can lead to hearing loss. The nurse should check the client's hearing and report any changes to the provider. The provider may adjust the dose or frequency of vancomycin, or switch to another antibiotic.

Choice D reason: Localized redness at the catheter insertion site is not the nurse's priority to report to the provider. Redness at the catheter insertion site may indicate irritation, inflammation, or infection of the skin or vein, and may be caused by the needle, the catheter, or the medication. The nurse should inspect the site, clean it with antiseptic, and apply a sterile dressing. The nurse should also monitor the site for signs of phlebitis, such as pain, swelling, warmth, or pus. The nurse may need to change the catheter or the infusion site if the redness persists or worsens.

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Correct Answer is C

Explanation

Choice A reason: Migraines are not a contraindication for propranolol. In fact, propranolol is used as a prophylactic treatment for migraines, as it reduces the frequency and severity of migraine attacks.

Choice B reason: Glaucoma is not a contraindication for propranolol. Propranolol does not affect the intraocular pressure or the drainage of aqueous humor in the eye.

Choice C reason: Asthma is a contraindication for propranolol. Propranolol is a nonselective beta-blocker, which means it blocks both beta-1 and beta-2 receptors in the body. Beta-2 receptors are found in the bronchial smooth muscle, and when they are blocked, they cause bronchoconstriction and increased airway resistance. This can worsen the symptoms of asthma and cause a life-threatening asthma attack.

Choice D reason: Depression is not a contraindication for propranolol. Propranolol does not cause depression, although it may cause some side effects such as fatigue, insomnia, and sexual dysfunction. However, these side effects are usually mild and reversible.

A. Naloxone B. Protamine C. Calcium gluconate D. Flumazenil

Correct Answer is C

Explanation

Choice A reason: Naloxone is not the correct medication. Naloxone is an opioid antagonist that reverses the effects of opioid overdose, such as respiratory depression, sedation, and hypotension. Naloxone has no effect on magnesium sulfate, which is a mineral and electrolyte that is used to prevent seizures in clients with preeclampsia or eclampsia.

Choice B reason: Protamine is not the correct medication. Protamine is a heparin antagonist that reverses the effects of heparin overdose, such as bleeding, bruising, and thrombocytopenia. Protamine has no effect on magnesium sulfate, which is not an anticoagulant.

Choice C reason: Calcium gluconate is the correct medication. Calcium gluconate is a calcium salt that antagonizes the effects of magnesium sulfate overdose, such as hypotension, bradycardia, respiratory depression, and muscle weakness. Calcium gluconate is the antidote for magnesium sulfate toxicity, which can occur when the serum magnesium level is above 7.5 mEq/L. The nurse should monitor the client's vital signs, deep tendon reflexes, and urine output, and report any signs of toxicity to the provider.

Choice D reason: Flumazenil is not the correct medication. Flumazenil is a benzodiazepine antagonist that reverses the effects of benzodiazepine overdose, such as drowsiness, confusion, and coma. Flumazenil has no effect on magnesium sulfate, which is not a sedative.

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A nurse is assessing a client after administering IV vancomycin. Which of the following findings is the nurse's priority to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions?

Correct Answer is C

Explanation

A client who is receiving magnesium sulfate has a urine output of 20 mL/hr. Which of the following medications should the nurse expect to administer?

Correct Answer is C

Explanation

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