A nurse is assessing a client who is receiving IV vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?

Document that the client experienced an anaphylactic reaction to the medication.

Decrease the infusion rate on the IV.

Apply cold compresses to the neck area.

Change the IV infusion site.

Answer and Explanation

The Correct Answer is B

A. The symptoms described (flushing and tachycardia) are not indicative of an anaphylactic reaction, which typically includes symptoms like difficulty breathing, hives, or swelling. Documenting it as an anaphylactic reaction would be misleading and could lead to inappropriate management.
B.   Slowing the infusion rate can help mitigate the symptoms of Red Man Syndrome, which is often related to the rate of vancomycin administration. The recommended infusion rate for vancomycin is generally over at least 60 minutes, and reducing the rate can help alleviate symptoms.
C.   Applying cold compresses should help with pain but as important like documentation.
D.   The infusion should be continued and not used again for the client.

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Correct Answer is B

Explanation

Extended release potassium chloride tablets should be taken whole to avoid rapid release of the potassium which may lead to hyperkalemia and GI irritation.

A. Diuretic therapy increases urine output through reduction of water reabsorption. Potassium supplementation does not interfere with its action.

C. Taking potassium chloride with food or after meals is recommended to reduce the risk of gastrointestinal irritation or discomfort.

D. Antacids interfere with the absorption of potassium chloride leading to inadequate supplementation.

A. "Clients who have glaucoma should not take warfarin." B. "Clients who have rheumatoid arthritis should not take warfarin." C. "Clients who are pregnant should not take warfarin." D. "Clients who have hyperthyroidism should not take warfarin."

Correct Answer is C

Explanation

Warfarin is a coumarin anticoagulant that has potential to increase the risk of bleeding. When taken during pregnancy, warfarin causes fetal bleeding. Warfarin is also teratogenic and it causes various birth defects including skeletal abnormalities, hypoplastic nose, intellectual disabilities and deafness hence it's contraindicated. Pregnant women who require anticoagulation are put of heparin in the place of warfarin to prevent these complications.
A. B, D - are not contraindications for warfarin use.

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A nurse is assessing a client who is receiving IV vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching for a client who is on diuretic therapy and has a new prescription for potassium chloride (KCL) 20 mEq extended release PO daily. Which of the following instructions should the nurse provide about the new prescription?

Correct Answer is B

Explanation

A nurse is educating a group of clients about the contraindications of warfarin therapy. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

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